
Glass KB 34 
Book . V/ pg 



\i 



\ 






SURGICAL OBSERVATIONS, 



CASES AND OPERATIONS 



J: MASON WAEREN, M.D., 

SURGEON TO THE MASSACHUSETTS GENERAL HOSPITAL; FELLOW OF THE 
AMERICAN ACADEMY OF ARTS AND SCIENCES, ETC. 




BOSTON: 
TICKNOR AND FIELDS. 

1867. 



\J-b^ 



VVa 



^ 



Entered according to Act of Congress, in the year 1867, bj' 

J. MASON WARKEN, 

in the Clerk's Office of the District Court of the District of Massachusetts. 



CAMBRIDGE : 
PRESS OF JOHN WILSON AND 



TO 



EGBERT HOOPER, Esq., 

PRESIDENT, 

EDWAKD WIGGLESWORTH, Esq., Vice-President, 

J. THOMAS STEVENSON, Esq., Treasurer, 

THOMAS B. HALL, Esq., Secretary, 

©f t!je JHagsacJusetts (General ^o&piidl; 

And to the Trustees, 

Henry B. Eogers, Samuel G. Howe, 

James M. Beebe, James L. Little, 

William S. Bullard, John Lowell, 

Charles H. Dalton, Ezra Farnsworth, 

Samuel Eliot, Charles S. Storrow, 

George Higginson, '' Henry A. Whitney, Esq.'s, 

Under whose wise management the Institution has attained its present importance 
to Humanity and Science, 

Is inscribed, as a Testimonial of respect and esteem, 

BY THE AUTHOR. 



This volume contains some results of surgical experience, 
and develops and illustrates what was advanced by the author 
in an address delivered before the Massachusetts Medical 
Society, and entitled "Recent Progress in Surgery." 

The cases which are cited have been mostly derived from 
practice in the Massachusetts General Hospital ; and some of 
them have been previously published. Many others might 
have been given ; but it has been thought proper to relate only 
those of which the histories have been well ascertained. 

As a convenient method of classification, the regions of the 
body have been used ; and this order has been kept through 
the book, except in the last chapters, which relate to Gunshot 
Wounds, Tumors, and Miscellaneous Cases. It is not pro- 
posed iru this volume to comprehend every surgical subject, or 
to enter into much descriptive detail ; but simply to indicate 
the chief points in the cases and operations which are recorded, 
and to add such remarks and conclusions as have seemed to be 
pertinent. 

Park Street, April, 1867. 



CONTENTS. 



CHAPTER I. 

THE HEAD. 

Page 

Fractures of the Cranium 1 

Trephining for Epilepsy 7 

Injuries of the Scalp 15 

Concussion of the Brain 16 



CHAPTER II. 

THE FACE. 

Rhinoplastic Operations 18 

Operations for the Restoration of the Lower Eyelid 42 

Epithelial Cancer and Rodent Ulcer 47 

The Eye 55 

The Ear 59 

Horns 60 

Deviation of Septum of Nose 62 

Tumors of the Jaw-bone 64 

Epulis 70 

Cystic Tumors of the Jaw 72 

Cancerous Tumors of the Jaw 80 

Fibrous Tumors of the Jaw 84 

Apparent Tumors of Lower Jaw, secondary to Removal of Cancer 

of Lip 1 86 

Necrosis of Jaw 88 

The Tongue 92 

Salivary Calculus 94 



Xll CONTENTS. 

CHAPTER III. 

THE NECK. 

Page 

Foreign Bodies in the Air-passages 9(3 

Croup. Tracheotomy 108 

Foreign Bodies in the GEsophagns 112 

Stricture of the Oesophagus 114 

Tumors in the Oesophagus 116 

Removal of Tonsils 119 

Fissure of Soft and Hard Palate 126 

Harelip 143 

CHAPTER IV. 

THE CHEST. 

Paracentesis Thoracis 146 

CHAPTER Y. 

THE A B D O M E X. 

Hernia. — Strangulated Hernia 152 

Radical Cure of Hernia 164 

Artificial Anus 168 

Iliac Tumor 179 



CHAPTER VI. 

ANUS. 

Hemorrhoids . > , 183 

Fissure of the Anus 186 

Fistula in Ano 191 

Fistulous Opening containing Hair 192 

Prolapsus Ani 194 

Polypus of the Rectum 195 

Imperforate Anus and Rectum 196 



CHAPTER VIT. 

GENITO-URINARY ORGANS. 

Stone in the Bladder 204 

Stricture of the Urethra, with Retention of Urine 226 



CONTENTS. Xlll 



Page 

Perineal Section 2oO 

Diseases of the Prostate 240 

Wound of the Bladder 241 

Vesico-rectal Fistula 242 

Cancer of Rectum 243 

Indurated Tumor of Penis 245 

Tumors of the Spermatic Cord 248 

Phimosis 250 

Hydrocele 251 

Hsematocele 252 

Varicocele 254 

Retained Testicle 257 

fi:male gexito-urinary organs. 

Rupture of the Perinasum 258 

Vesico-vaginal Fistula 263 

Prolapse of Walls of the Vagina 268 

A'^ascular and Sensitive Tumor of Female Urethra 270 

Cancer of Vulva 272 

Tumor of Vagina 273 

Polypus Uteri 274 

Foreign Body in Vagina 276 

Occlusion of the Vagina 278 

Occlusion of Os Uteri 291 

Hypertrophy of Cervix Uteri 294 

Ovariotomy 300 

Calculus 303' 

Absence of Vagina and Uterus 306 

Hermaphrodism 310 



CHAPTER VIII. 

THE EXTREMITIES. 

Fractures 318 

Dislocations 348 

Amputations 384 

Excision of Joints 409 



CHAPTER IX. 



ARTERIES AND VEIN 



Aneurismal Tumors, and Ligatures of Arteries 424 

Vascular or Erectile Tumor 44 1 



XIV CONTENTS. 



CHAPTER X. 

Page 
INJURIES AND DISEASES OF NERVES. 465 



CHAPTER XI. 

TUMORS. 

Tumors 479 

Tumors in the Parotid Region 488 

Leucocythaemia 501 

Operations for Cancer (Table) 536 

CHAPTER XII. 

GUNSHOT WOUNDS. 542 

CHAPTER XIII. 

MISCELLANEOUS CASES. 

Penetrating Wounds of Chest and Abdomen 569 

Hip and Spinal Diseases 572 

Appendix Vermiformis 575 

Hydrophobia 584 

Extraction of Needles 590 

Injuries of the Os Coccygis 593 

Fracture of the Base of Skull , 597 

Wry Neck 601 

Congenital Fusion of Fingers 609 

CHAPTER XIV. 

ANAESTHETICS. 

Ether and Chloroform 613 

Local Anaesthesia 621 



ILLUSTRATIONS. 



Page 

Frontispiece. — Fungoid Tumor of Forehead. See 483 

Woodcut. — Destruction of Nose, Case XIII 20 

Rhinoplastic Operation for, Case XIII 25 

Taliacotian Rhinoplasty 33 

37 

Tumor of Oesophagus 117 

Section of Xeck representing the Tumor in situ . . . 118 

Tonsillotome 123 

Median Fissure of Hard Palate 140 

Plate I. — Instruments used in Operations for Cleft Palate .... 142 

Woodcut (after Huguier). — Hypertrophy of Cervix Uteri .... 298 

Dislocation of Thigh Downwards 378 

Plate II. — Subclavian Aneurism 425 

,, III. — Erectile Tumor of Face and Xeck 446 

, , IV. — The same after Operation 449 

AYooDCUT. — Tumor of Head 485 

Parotid Tumor 495 

,, Tumor of Arm 520 

Plate V. — Tumor of Os Frontis, containing' Air 576 



SURGICAL OBSERVATIONS 



CHAPTEE L 

THE HEAD. 
FRACTURES OF THE CRANIUM. 

It is very frequently observed, that extensive injuries of the 
head, with comminuted fracture of the skull, do remarkably 
well, even when there has been laceration of the membranes and 
considerable loss of cerebral substance. The cases which are, 
perhaps, most to be dreaded are those in which the depression 
is limited, and the fragments so firmly locked as to require the 
operation of trephining for their replacement. In those cases, 
the results appear to be generally unfavorable. The question 
of trephining in cases of injury of the skull with depression, 
both immediately after the accident where no cerebral disturb- 
ance is present, and at a later period when epileptic symptoms 
have come on in consequence of the uTitation produced by the 
depressed piece of bone, is, however, still an open one. Many 
cases in which there is considerable depression of the skull, and 
in which not the slightest cerebral disturbance has appeared at 
the time of the accident, are subject, after the first depression 
caused by the injury has disappeared, to chronic headaches ; 
and I have seen a number who, a year or more afterwards, 
have been seized with epileptic convulsions, and have then 
urgently sought the relief promised by an operation. Extreme 
doubt must always exist, in these cases, as to the probable suc- 
cess of any operation for elevating the bone after so long a 

1 



2 THE HEAD. 

period, especially as we must almost always be in total igno- 
rance of the extent to which the dura mater and arachnoid 
membranes are implicated in the original injury. 

Patients are often so excessively urgent, however, in their 
desires for relief, and their lives are rendered so wretched by 
their sufferings, that it seems fair, in certain cases, to attempt 
the operation, when we are sure that its danger and uncertainties 
are fully understood by themselves and their friends. Some- 
times, however, a state of partial derangement seems to follow 
from the effects of the injury ; in which case they may insist on 
an operation where there is little or no chance of benefit. 

The diagnosis of fracture of the cranium is occasionally ex- 
ceedingly difficult, especially in the case of children who have 
suffered from blows on the head. After these accidents, we 
very often observe a remarkable phenomenon about the scalp, 
suggesting a depression of the skull : this appearance is so 
deceptive that practised surgeons will often be at variance in 
the opinion whether the skull is depressed or not ; a matter 
sometimes of considerable consequence, if symptoms of com- 
pression happen to be present. Sometimes, however, with 
young children, even if the skull is depressed, it seems after a 
time to rise up, and resume its natural position. On the other 
hand, in one instance which I remember, where it was supposed 
that the appearances of depression were entirely caused by the 
injury of the scalp and periosteum, and where no symptoms 
called for an operation, it was found, that at the end of three or 
four weeks, after all swelling had subsided, a depression really 
existed. 

Case I. — Extensive Compound Fracture of the Skull. 
Recovery. — May 18, 1852, I was requested to see a fine, 
handsome boy, aged 12, who, the night before, had fallen a 
distance of twenty-five feet, striking on the right parietal bone, 
and producing an extensive compound comminuted fracture. He 
had been insensible at first, and in a collapsed state ; but had 
gradually recovered vitality, and, when I saw him, was sensible. 
Portions of brain escaped from the wound. By the aid of in- 
cisions, loose bits of bone were removed, and a large quad- 



FRACTUEES OF THE CRAXIU3I. d 

rangular depressed portion — extending up towards the vertex 
-7- was elevated. Another portion, driven under the adjacent 
bones, was removed. The rough edges of bone were smoothed 
off with Hey's saw. Cold-water dressings were applied to the 
wound. He was kept under strict diet, very carefully watched, 
and recovered completely. 

> Ten years afterwards he entered the army, when he suffered 
the first inconvenience from his former injury, concussions of 
cannon producing such a stunning effect upon the brain as to 
cause vertigo, and ultimately obliged him to quit the service. 

Case II. — Extensive Fracture of the Base of the Skidl, 
and JRupture of the Opposite Side of the Brain. Death 
after ten days. Bemarhahle Absence of Symjjtoms indi- 
cative of so severe an Injury. — May 18, 1858, a woman was 
brought into the Hospital, and died after a few days, with very 
deceptive symptoms. A week before, while reaching out of a 
third-story window, she lost her balance, and fell, first upon a 
shed, and thence into the street. She was taken up insensible, 
but soon recovered herself sufficiently to speak, though inco- 
herently. She was supposed at first to be laboring under the 
effects of opium, which she was in the habit of taking freely, 
and a large bit of which was found in her pocket. When 
brought into the Hospital, a wound was discovered over the 
right parietal bone ; but the finger, being passed in, could detect 
no fracture. The head was carefully examined in every direc- 
tion ; but no fracture could be found. The patient exhibited 
signs of concussion, but none of compression, of the brain. 
There was no vomiting, no dilatation of the pupils, no bleeding 
from the ear. She was uneasy and restless, like a person under 
the influence of spirit, to which, and opium, her symptoms were 
mainly attributed. She gradually improved, and, after a day 
or two, got out of bed to search the drawer of the table for 
the opium which had been taken out of her pocket. On the 
tenth day after the injury, when she seemed much better, and 
answered the questions of the nurse coherently, a friend made 
her a visit, and brought her a bit of opium. The same night 
she suddenly died. 



4 THE HEAD. 

At first, it was very naturally supposed that the opium which 
she had taken was the cause of the sudden change in her symp- 
toms ; but the post-mortem examination, made by Dr. Ellis, re- 
vealed the following very severe injuries of the skull and brain : 

An extensive fracture was found at the base of the skull, 
on the right side, passing behind the auditory foramen, and into 
the foramen magnum : this was met by another fracture at 
right angles to it. On raising the dura mater from the opposite 
side of the brain, a layer of blood was seen spread over the 
whole of it ; and the middle lobe of the cerebrum was most 
extensively lacerated. 

In this case, nearly all the symptoms seemed to be explica- 
ble by supposing concussion combined with a state of delirium 
tremens, caused by the constant use of narcotics ; and, without 
an examination after death, the fatal termination would have 
been attributed to this cause, brought on by the shock from 
the fall, and assisted by the dose of opium given to her that 



Case III. — Extensive Fracture of the Base of the Shidl, 
and of the Bones of the Face. Death after ten hours. Pre- 
vious Injury of the Head, with prolonged JJyiconsciousness. — 
A gentleman 68 years of age, while driving a young horse, and 
being unable to control him, was seen to jump out of the sleigh 
in which he was riding, still holding on to the reins. A person 
seized the horse by the head, and requested the gentleman to let 
go the reins, which, however, he either could not or would not do. 
The horse going on, he was brought up violently against a tree, 
striking the side of his head. Assistance arriving, he gave his 
name and residence, was taken home, a distance of three miles, 
all the time making violent muscular movements. He lived 
twelve hours, depression coming on very suddenly. The effu- 
sion of blood under the skin of the face was so great as wholly 
to obliterate his features. Blood ran freely, also, from the left 
ear. 

On examination, twelve hours after death, it was found that 
the whole front part of the face had been broken away from 
the bones of the head, the fracture extending through both 



FEACTURES OF THE CRANIUM. 5 

orbits. The fracture was found also to extend throu£rli the 
body of the sphenoid, and another through the petrous portion of 
the temporal bone, so that a probe passed freely from the exter- 
nal auditory meatus into the cavity of the cranium. The 
middle lobe of the left cerebral hemisphere was filled with co- 
agulated blood. The amount of injury was greater than I have 
ever witnessed in a case of fracture of the skull ; yet he was 
able to give his name and address, and lived twelve hours after 
the receipt of the injury. 

This gentleman, thirteen months before, was knocked down 
by a sled, striking the left side of his head, and breaking the 
left clavicle near its outer third, with great displacement of 
the fragments. He remained in a partially unconscious state for 
three weeks, and would not submit to any treatment for the frac- 
tured bone. His left leg he moved with difficulty, either from 
some blow which he had received upon it, or, as was supposed at 
the time, from a partial paralysis dependent on the blow on the 
head. During the greater part of this time, he complained of 
excessive pain in the head, requiring the constant use of cold 
applications. He finally completely recovered, without appa- 
rent symptoms of having sustained any severe injury. As 
soon as he would allow it, his arm was kept confined by 
bandages, for a period of three weeks. At the present examina- 
tion, we were naturally desirous of investigating the cause of the 
extraordinarily prolonged cerebral symptoms : no signs, how- 
ever, could be discovered, either of old fracture or of thickening 
of the dura mater at the spot where the blow had been received, 
nor were there any other marks of disease in the immediate 
investing membranes of the brain. The only appearance of 
disease was a strong adhesion of a small portion of the right 
side of the brain to the dura mater, so firm that a part of the 
brain was torn away in separating it. The clavicle, which for 
three weeks had had no treatment, and in fact had been vio- 
lently thrown about in all directions, had firmly united, and was 
shortened about three-fourths of an inch, but without any pro- 
jecting angle, — a good commentary on the subsequent necessity 
for using complicated bandages in the treatment of these in- 
juries. 



b THE HEAD. 

It may be stated, that, just before the receipt of his fatal in- 
jury, he informed me that he could scarcely tell on which side 
the clavicle had been fractured, return of power in the injured 
limb having been so complete. 

Case TV. — Gunshot Fracture of the Occipital Bone with- 
out immediate Symptom^s. Death after ticenty-five days from 
Abscess of the Brain. — Dr. Wheeler, of Chelsea, gave me an 
occipital bone, with a fracture through both tables, caused by a 
Minie ball. On the inner surface were several fragments which 
had been driven inwards, with rough spiculae, encroaching at 
least half an inch on the cavity of the cranium ; on the outside 
was an indentation corresponding in size and shape to the flat- 
tened ball. He also sent the following account of the case : — 

"A captain, 35 years of age, belonging to the Thirty-fifth 
Regiment of Massachusetts Volunteers, in a movement with 
the Ninth Army Corps, on the Weldon Railroad, near Peters- 
burg, Ya., in action on the nineteenth day of August (1864), 
received a wound of the scalp upon the back of the head, by a 
rifle-ball striking the occipital bone near the apex, and just with- 
in the lambdoidal suture of the right side. The immediate effect 
of the concussion caused him to fall, with a momentary faint- 
ness and loss of his eyesight ; but his consciousness was retained. 
In a few moments he was able to get up, and walked to the rear, 
where the ball was picked out from its bed under the scalp. 
No symptoms of compression were present, no fracture was 
then suspected, and the injury was recorded as a flesh wound. 
He was transferred to City Point, Va. , and from thence to a 
general Hospital near New- York City, where he remained, very 
comfortable, some eight or ten days. He was then furloughed, 
and arrived home (near Boston) on the first day of September 
following. He complained but little of his head, but said that it 
felt heavy at times, and that his eyesight was not quite as good 
as usual. These symptoms did not confine him at home : he 
walked out, called to see his friends, and also attended in 
person to some business matters. The wound in the scalp was 
suppurating moderately, and was looking well. The day he ar- 
rived home, a fissure and depression of bone were discovered to 



TKEPHINING FOR EPILEPSY. 7 

exist ; but, as no symptoms of compression or cerebral disturb- 
ance were present, it was thought that surgical interference was 
hardly called for. But about the 7th of September, or some 
eighteen days after the date of the injury, he complained of a 
chill, which was followed by fever and pain in the back of the 
head; and, in a few hours, slight delirium came on. The de- 
lirium, heat, and other symptoms became more severe from day 
to day, finally ending in profound coma, with slight convul- 
sions. He died on the 15th of September, just twenty-five 
days after the injury." 

An autopsy exhibited a fracture of the occipital bone. In 
addition to the appearances mentioned above, " the dura mater 
gave signs of active inflammation in a circular spot of about 
two inches in diameter. It was not lacerated, was quite dark 
in color, and readily separated from the bone. Just beneath 
this portion of the membrane was found a well-defined abscess, 
containing about two ounces of pus, formed in the substance of 
the brain. 

"The history of this case, with but a glance at the bony 
specimen, will at once suggest the trephine and its early use as 
the best means to ward oft inflammation and its consequences." 



TREPHINING TOR EPILEPSY. 

Case V. — Oi^evations on the Head for Einlepsy folloio- 
ing Injury of the Skull. TrejMning for an old Depres- 
sion causing Convulsions and Idiocy. — This girl, 10 years 
of age, was struck in infancy upon the head ; and, although the 
corporeal faculties had developed normally, there had been little, 
if any, manifestation of intelligence. The child recognized im- 
perfectly her parents ; was a voracious eater ; excessively strong, 
wild, and unmanageable, at times so violent that it was impos- 
sible to restrain her. She was unable to articulate, but would 
frequently run through the house, uttering a kind of howl, and 
leaping to the distance of many feet like a wild beast. She 
was also subject to the most distressing convulsions. Under 
these circumstances she was brought to me, with the earnest 
request that I would endeavor to do something for her relief. 



O THE HEAD. 

On examination, there was found, extending across the head, 
just behind the coronal suture, a longitudinal depression, three 
to four inches in length by one in width. I suggested to the 
parents — giving them to fully understand its danger — the 
removal of the depressed portion, as the only remedy which oc- 
curred to me. This being submitted to a consultation of the 
surgeons of the Hospital, it was determined to advise it, con- 
sidering the desperate nature of the case. When brought into 
the amphitheatre, the patient rushed in with her head down, 
hardly restrained by the strength of two men. After she had 
been brought under the influence of ether, the necessary incis- 
ions were made through the integuments, the bone was cut 
through with two crowns of the trephine, and the openings 
joined by cutting out the intermediate piece with a Hey's saw. 

For the first six days she did well; but died, on the ninth, 
from a bleeding from the longitudinal sinus, which ruptured after 
some sudden and violent movement made by the patient in 
bed. The father thought there was an appreciable increase of 
the amount of intelligence after the operation ; and it was obvi- 
ous to every one, that she took cognizance of persons and things 
about her in a way she had never done before. 

I partly attribute the failure of this operation to my follow- 
ing the suggestion of a bystander, and sewing up the wound, 
instead of allowing the flap to fall down, and adhere to the parts 
beneath. The consequence was, that pus collected in the cavity 
formed by the scalp, causing decomposition of the dura mater, 
which assisted in eroding the textures beneath.. 

Case YI. — Trephining for Depression of the Skull caus- 
ing Epilepsy. — J. C, 21 years of age, applied to me, Oct. 
25, 1850, and gave the following account of himself. Four- 
teen years before, he had fallen against a post, and received a 
severe blow on the left side of his head. His scalp was cut 
open, but there was no perceptible fracture of the skull. With- 
in a year after the accident, he was attacked with epileptic fits, 
to which he was subsequently subject, at intervals of one or 
two months. The attacks were followed by pain and drowsi- 
ness. The pain was felt chiefly at the point where the in- 



TREPHIXIXG FOR EPILEPSY. 9 

jury was received, and also over the right orbit. His memory 
was impaired ; he was erratic, impetuous, and unmanageable. 
The bone, at the seat of the injury, appeared thickened and sen- 
sitive. Finding that he was becoming a burden to himself, 
and in danger of losing his mind, he applied to me to perform 
the operation of trephining, having informed himself on all 
points with regard to it. Oct. 26, 1850, being etherized, 
his scalp was raised by a V-shaped incision over the injured 
part ; and a trephine, one inch in diameter, was applied 
over the suture between the frontal and parietal bones. On 
raising the bone, the frontal was found to be more than three 
times as thick as the parietal. A simple water dressing was 
applied to the wound. Oct. 27, the day following the opera- 
tion, the Hospital record states that he had severe vomiting ; 
his pulse was ninety-six. On the 28th, he complained of head- 
ache, but had some sleep through the night. The next week or 
two, he had more or less pain in the head, but gradually im- 
proved. Nov. 28th, he seemed quite well, and the incision 
made by the operation was healed. He remained under my 
cognizance a month longer and was finally discharged Dec. 
24th, having had no epileptic attack during the two months 
that he remained in the Hospital ; and his moral and physical 
condition otherwise materially improved. 

I heard from him some months afterwards, and he made a 
good report. He subsequently, however, as I understood, fell 
into irregular habits, and died ultimately with a cerebral attack. 

Case VH. — Operation for Depression of the Shidl caused 
by a red-hot Poher passing through the Bones, and penetrat- 
ing the Brain. — A fine-looking young man, 22 years of age, 
a Nova Scotian by birth, applied to me in December, 1857, on 
account of severe epileptic fits, caused by a depression of the 
skull from an injury he had received three years before. His 
account of the circumstance was this : He was by trade a 
blacksmith ; and, while engaged at work, playfully threw some 
article at a fellow-workman near him. This person returned it, 
by throwing at him a red-hot poker, which he had in his hand. 
The poker struck him on the frontal bone, just above the orbit : 

2 



10 THE HEAD. 

it passed through the bone, and entered about three inches into 
the cerebral substance. He immediately seized the instrument 
himself, and drew it out by main force. There was but little 
bleeding from the wound. He did not at the moment become 
insensible ; but, an hour afterwards, he fell into a comatose 
state, in which he remained for a part of the rest of the day. 
He was very carefully attended by Dr. Hooker, of East Cam- 
bridge ; and in about three months the wound was sufficiently 
well, and his health so far restored as to allow him to resume 
his business. 

About four months after the injury, he was seized with a 
severe epileptic convulsion ; and these attacks have followed 
pretty regularly since, at intervals of three months. He 
says he falls very suddenly without the slightest warning, 
and sometimes injures himself severely. He lately fell back- 
wards upon his anvil, striking the back part of his head, and 
cutting the scalp, behind the ear, down to the bone. The 
convulsions, of late, have increased in frequency ; and he feared 
lest his mind should become affected by them. He was also 
apprehensive that he might some day, while at work, fall into 
the fire, and burn or seriously injure himself. Under these 
circumstances, both he and his friends were very urgent to have 
an operation performed. 

On an examination of his head, a depressed portion of skull, 
of the size of half a dollar, was found just over the right internal 
angular process, partly implicating the frontal sinus. In the 
centre of this depression the skull was deficient, and a thick 
strong cicatrix indicated the point at which the dura mater was 
adherent to the integument. The pulsations of the brain were 
here distinctly visible. 

After seeing this patient once or twice, and carefully investi- 
gating his case, I finally advised an operation, fully informing 
him of the hazard of it. He entered the Hospital ; and the 
surgeons, in consultation, having concurred in the propriety of 
my opinion, the operation was performed on Dec. 24th. 

The principal difficulty consisted in fixing the trephine so as 
to make it take hold of the skull, on account of the impossibility 
of using the pin, from the bony deficiency in the centre of the de- 



TREPHINING FOR EPILEPSY. 11 

pression. To meet this difficulty, a bit of thick leather, which 
had been previously prepared with a hole in it to receive the 
trephine, was fixed to the head ; but this, in practice, was found 
not to answer its intended purpose. After considerable labor, 
the trephine was made to take hold ; and the rest of the opera- 
tion was done with a moderate degree of facility. The portion 
of bone removed entire comprised about half a circle ; the 
anterior part, being that which formed the roof of the frontal 
sinus, came away in bits. From the interior of the portion 
removed, a sharp spine projected, which was imbedded in the 
brain. The membranes of the brain, where they penetrated 
the bone and adhered to the scalp, were carefully separated from 
their attachment to the bone by means of a probe ; being at one 
point so excessively thin and delicate as to have hardly the 
consistency of blotting-paper. Here an inevitable tear took 
place, with the escape of a very minute quantity of limpid fluid 
from within. This was the only unsatisfactory occurrence in the 
course of the operation. The wound was very lightly dressed, 
and no sutures used. 

In the afternoon, the patient was sitting up in bed, quite 
bright, and seemed scarcely affected by the operation. On the 
following day, he said he was doing well, and had passed a 
good night. On the third day, he was not so well : his face 
was flushed, pulse ninety, skin hot ; and he seemed indisposed 
to talk. There were evident signs of inflammation of the mem- 
branes of the brain. An active cathartic was administered, and 
cold applications were made to the head. On Dec. 27th, the 
third day after the operation, I found him almost insensible ; 
pupils not dilated ; pulse one hundred and nineteen. Sixteen 
ounces of blood were taken from him. The symptoms had 
Increased in severity by the following day ; and, in the course of 
it, he died. 

By permission of his friends, an examination of the body 
was made by Dr. Ellis, on the day after his decease. The 
whole surface of the arachnoid, on the side affected, was covered 
with pus ; and some was found underneath that membrane. At 
the point of injury, extending two inches into the brain, there 
was an orojanized clot still retaining somewhat of its color, and 



12 THE HEAD. 

showing distinctly the course pursued by the red-hot iron three 
years before. The inner surface of the skull was smooth ; and 
adherent to the edges of it (where it had been divided by the 
saw) were two small, flat, ivory-looking pieces of bone, about the 
circumference of a pea. These bits had probably been origin- 
ally detached by the poker, but were now firmly adherent to 
the bone. 

RemarJcs. — In view of the great difficulty of fixing the tre- 
phine in this operation, it occurred to me afterwards, whether 
any other plan could have offered better chances for despatch. 
The only one which suggested itself was to have made a num- 
ber of holes around the circumferences of the opening in the 
skull, and connect these different perforations by a small saw. 

The non-success of the operation must be attributed to the 
perforation of the membranes, at the point of their intimate 
connection with the aperture in the bone, where they passed 
through to form a union with the scalp ; and this, apparently, 
no care could have avoided. 

Case YIII. — Case of Dejpression of the Internal Tahle of 
the SlculU causing Epilepsy. — M. N., 18 years of age, 
entered the Hospital in April, 1865, for the purpose of having 
an operation done for trephining the skull, on account of a de- 
pression causing epilepsy. He stated that, six years before, he 
had been kicked in the head by a horse, that his skull had been 
fractured and depressed, and that he had been unconscious for 
several weeks. There is some doubt in regard to this part of 
his account, as he was seen by practised surgeons, and no opera- 
tion was thought necessary. He recovered from the accident in 
about four months, and returned to work. He remained well 
until March, 1864, when he was seized with an epileptic fit, and 
remained unconscious for fifteen minutes. He had two similar 
attacks in May, one in December, and one in February, 1865. 
Since the 1st of January, 1865, he had suffered from general 
weakness, loss of appetite, tenderness in the epigastrium ; his 
speech was stuttering ; and he complained of a constant ticking 
sound in his head. An examination of his head disclosed an 
apparent extensive depression of the parietal bone, above and 



TREPHINING FOR EPILEPSY. 13 

behind the left ear. Although he was urgent for an operation, 
and, on a consultation, it was decided that an operation was ap- 
propriate, I was very reluctant to proceed to it, from the great 
uncertainty attending operations for trephining in these cases, 
and therefore decided first to try the effects of treatment. 

He was kept quiet, dieted, had a seton put in the back of 
his neck, and took ten grains of bromide of potassium twice a 
day. At the end of five or six weeks, an extensive eruption 
of acne appeared on the face, and the bromide was discontinued. 
He remained in the Hospital three weeks, under treatment, 
and, during that time, had no convulsions : it was therefore de- 
cided that he should go into the country for the summer, and 
continue the treatment. Throughout the summer, he had but a 
single convulsion ; but that lasted an hour and a half. He 
entered the Hospital again in January, 1866, insisting on an 
operation. Since his last attack, his symptoms had all been 
aggravated; his head "felt as if it would split open," and he 
was almost afraid to lie down, on account of the ao-oTavatlon 
of this sensation; the stomach was much distended with flatus, 
and he had nausea after eatincr. 

o 

The scalp having been shaved, the vacuity In the bones be- 
came more evident, and a pulsation was detected as if coming 
from the brain : this was not constant, but was most observed 
principally when he rose up suddenty. On deep j)i'essure, a 
resistance was felt ; and it was not possible to say, w4th cer- 
tainty, that any part of the skull was deficient at this spot. 

The patient, having been properly prepared for the operation 
by a purgative the day before, and taken nothing but liquid for 
breakfast, was etherized. A circular incision, describing two- 
thu'ds of a circle, was made through the scalp, with the con- 
vexity extending below the depression ; the flap, being dissected 
up, uncovered a space about three inches in diameter. It was 
at once found, on raising the flap, and scraping up the perios- 
teum at the edge of the depression, that the bone was completely 
deficient at that point, which was filled up with the membranes 
of the brain, through which the pulsations of that organ were 
distinctly observed. The external table of the skull did not seem 
depressed, and it was impossible to say what had become of the 



14 THE HEAD. 

deficient fragments. A small quantity of the arachnoid fluid 
could be seen trickling out, exactly from what point could not 
be detected. As no trephining operation seemed indicated, and 
as it was impossible to proceed without opening the cerebral 
coverings, it was decided to desist from farther proceedings. 
The flap was accordingly brought down, and secured by sutures. 
In the afternoon, he had recovered from the ether, expressed 
himself relieved, and the following day was in a very satisfac- 
tory condition. On the 26th of January, two days after the 
operation, he began to be confused in his mind : his strength 
seemed to fail, and he could not answer questions. On the 
27th, he had an epileptic fit, lasting half an hour. On the 28th, 
he had a continued succession of fits ; the left pupil was dilated, 
and the urine passed involuntarily ; pulse one hundred and 
twenty ; the right leg was paralyzed. On the 29th, he died 
about 2-|-, P.M. 

On post-mortem examination of the head, there was an ex- 
tensive inflammatory deposit between the arachnoid and pia 
mater ; the veins of the brain, on the left side, were greatly 
eno^oro^ed. The effects of the accident on the skull were re- 
markable : for a space of three inches or more beneath the 
opening in the skull, the internal table was depressed nearly 
three-quarters of an inch below the level of the external table, 
this depression extending off* on each side for some distance ; 
the dura mater and arachnoid projected through this fissure, 
and were attached around the margin of the external opening, 
which, at some parts, was simply filled with the arachnoid alone ; 
through this, at one point, was a minute aperture, caused very 
possibly by the dissection of the scalp, which had been made at 
the time of the operation. From the condition of the skull, no 
operation, of course, which could have afforded him relief, would 
have been practicable. The case is an instance of the entire 
uncertainty which we must be prepared to encounter when we 
proceed to an operation of this description. 



INJURIES OF THE SCALP. 



15 



Cases of Trephining for Epilepsy occurring at the Massachusetts General Hospital. 



DATE. 


SEX. 


AGE. 


CAUSE. 


RESULT. 


TIME. 


Feb. 22, 1832 


F- 


23 


Depression with Epilepsy 


Cured 


4 months 


Sept. 19, 1842 


M. 


26 


Epilepsy 


Died 


8 weeks 


May 27, 1838 


M. 


26 


Depression with Epilepsy 


Cured 


9i weeks 


Oct. 25, 1850 


M. 


21 


Epilepsy 


Rel'd 


2 months 


Dec. 19, 1850 


F. 


28 


Epilepsy 


Cured 


3^ months 


Dec. 24, 1857 


]\I. 


22 


Depression with Epilepsy 


Died 


4 days 


Aug. 18, 1860 


M. 


25 


Epilepsy after Fracture 


Died 


10 days 


Jan. 12, 1861 


M. 


37 


Epilepsy after Fracture 


Died 


5^ weeks 


Aug. 31, 1863 


M. 


25 


Depression with Epilepsy 


Eel'd 


3 weeks 


Jan. — 1866 


M. 


21 


Depression with Epilepsy 


Died 


6 days 



RECAPITULATION. 

Cured 3 

Relieved 2 

Died 5 

Whole number of cases . . 10 



INJURIES OF THE SCALP. 

The following cases of extensive laceration of the scaljD, with 
almost total denudation of the bones of the head, are reported 
as showing how promptly recovery may take place after sucJi 
injm'ies, even under circumstances seemingly most unfavorable. 



Case IX.' — A boy aged 12 was knocked over by a wagon, 
the wheel passing over his head, removing the whole scalp, from 
the top of his head, commencing at the occiput, and carrying it 
down over his eyes. When I saw him, about an hour after- 
wards, the surface of the inverted scalp and the denuded skull 
were still covered with dirt and gravel, although a partial at- 
tempt had been made to clean it by washing. After cleansing- 
it still farther, the skin was replaced, and secured by a great 
number of sutures. The whole united by the first intention, 
and with scarcely any suppuration or deformity. 



16 THE HEAD. 

Case X. — A man was brought into the Massachusetts Gen- 
eral Hospital, and came under my care, who had fallen from the 
tongue of his cart while asleep, the front fore-wheel of which 
had passed over his head, tearing and rolling up the entire scalp, 
and leaving it covering his face. 

After being thoroughly cleaned by having warm water 
squeezed over it, and the sponge being used as little as possible, 
it was replaced and secured by a large number of sutures. 

He recovered rapidly, without any suppuration, and with 
almost complete union by the first intention. 



CONCUSSION OF THE BRAIN. 

Case XI. — Concussion of the Brain, with complete Deaf- 
ness, and injury of Scalp. — A gentleman 60 years old was 
thrown from a chaise, in June, 1861, striking his head, tearing 
the scalp almost completely off, and producing a concussion of the 
brain, under which he remained insensible one or two weeks. He 
was afterwards informed by his medical attendant, that there 
had been some bleeding from the ears. The scalp was replaced, 
and united perfectly in about two months. He has never been 
able to hear the slightest sound since. He speaks well, how- 
ever, and with a good intonation of voice. He is a clergyman, 
and is able to preach. 

In February, 1862, he applied to me for advice. On exam- 
ining the ears, the drum of the right one was found to be 
uninjured ; the left was perforated, and red and fleshy in appear- 
ance, with a purulent discharge from its surface. I informed 
him, that but little benefit was to be expected from treatment. 

Case XII. — The following case of concussion is an instance 
of severe symptoms coming on a week after the injury ; show- 
ing the importance of care in the management of persons who 
have received severe blows on the head, though no symptoms, 
for the moment, are present : — 

A man aged 35 was brought to the Hospital, April 9, 1864, 
having had, the day before, slight convulsions, drowsiness, 
and an unwillingness to talk. A week before, he had fallen 



COXCUSSION OF THE BRAIN. 17 

out of his wagon, striking his head on the pavement. For 
six days no inconvenience followed the accident, and he did 
his work as usual. He walked from his house to the Hospital 
with the assistance of his wife. His appearance was sleepy. 
He complained of pain in the back of his head, where an eleva- 
tion of the cranium was felt, whicli might be normal, — an un- 
usual development of the occipital protuberance. Pressure upon 
this part caused him to throw his arms about, and complain of 
pain. His pupils were contracted ; pulse slow. 

April 10th, he was lying on his back, with his eyes closed. 
His 23upils were contracted, and the urine was passed involunta- 
rily. He was ordered a dose, ten gTains each, of calomel and 
jalap. On the 11th, the medicine had operated freely; he was 
more sensible, and answered questions ; urine as before. On the 
12th, he was again drowsy, and could not be roused to answer 
questions ; pulse fifty-two, small. April 13th, still drowsy. 
He was ordered an injection of weak mustard and water, and a 
blister applied to the back of his neck. April 14th, said he felt 
a great deal better. April 23d, he was somewhat stupid ; pain 
in his head ; pulse sixty-six. On the 28th, he was up and 
dressed, and his mind was clearer, and speech was much im- 
proved. April 29th, he was discharged, — well. 



CHAPTER II. 

THE FACE. 

RHINOPLASTIC OPERATIONS. 

The operation of rhinoplasty is of very ancient date. It had, 
however, for various reasons, fallen into most unmerited disrepute 
until between thirty and forty years since, when it was revived 
in Europe by Graefe, DiefFenbach, and Labat on the continent, 
and Liston in Great Britain. 

In the ancient operations of this kind, the lost organ was 
restored at the expense of the integuments in its immediate 
neighborhood. Advantage being taken of the extensibility of 
the skin of the cheeks, the integuments were dissected up on 
both sides of the nasal fossa, brought forward, and united in 
the centre by points of the interrupted suture. If the extensi- 
bility of the integuments was not sufficiently great, incisions 
were made in front of the ears, so as to diminish the tension of 
the skin : the wounds thus made were afterwards allowed to 
fill up by granulation. This operation, however, did not restore 
the form of the lost organ ; and the only advantage gained was 
a flap of skin to cover the existing deformity. The operation, 
which was afterwards adopted, and which now bears the name 
of the author, was that of Taliacotius. In this operation, it was 
required that the arm should be confined in contact with the 
face for ten or fifteen days, or until union had taken place. 
The disadvantages of this method are at once manifest : the 
length of time during which it was necessary to keep the limb 
in this painful condition, sufficient in some cases to produce 
partial paralysis, and the danger that ensued in the too early 
separation of the transplanted skin from its source of nutrition, 
were, of themselves, reasons of sufficient weight to cause it to 
fall into disuse. 



EHmOPLASTIC OPERATIONS. 19 

The operation which has attained the most celebrity, and 
which has been most frequently practised in France and Eng- 
land, is that which goes by the name of the Indian method, in 
which the flap is taken from the forehead. 

It was my good fortune to witness a very large number of 
operations by the Indian method by the distinguished M. Dief- 
fenbach, of Berlin, at the time of his visit to Paris in 1834. 

Soon after my return home, I had an opportunity of perform- 
ing several operations for the restoration of the nose ; em- 
ploying, in one case, the TaHacotian or Italian method ; and, in 
another case, taking the requisite material from the fore-arm. 
The Indian method I have very frequently employed ; in most 
cases, with excellent results. The scar left on the forehead is 
much less conspicuous than might be expected, and the great 
suffering to the patient which results from the confinement of the 
arm to the head in the Italian method is avoided. The principal 
inconvenience which I have observed in these operations depends 
upon the fact, that the material for the septum, and often for the 
tip of the nose, must be taken from the scalp. The consequence 
is, that the hair continues to grow upon these parts ; requiring 
frequent shaving, or extraction with forceps. Depilatories I 
have often tried, but have never found that they produce more 
than a transient effect. 

The following and some of the succeeding cases are the first 
performed in America with success, and probably gave the im- 
petus to the introduction of this class of operations. The 
Taliacotian operation, as performed by the discoverer, of trans- 
planting a portion of the skin from another part of the body, 
had not been adopted by modern European surgeons ; so that 
the cases of that operation mentioned below were probably the 
only ones that had been successfully done for a number of 
years ; — 

Case XIII. — Rhinoplastic Operation. — A young man, 
28 years of age, in the spring of 1834 received a blow on the 
nose, which dislocated the cartilage to the left side. This was 
followed by brief inflammatory action. As he was out of town, 
and at a distance from medical advice, nothing was done to re- 
place the cartilage, which remained permanently displaced. 



20 



THE FACE. 



In the following spring, a red spot appeared on the right 
cheek below the eye, which very soon increased in size ; the 
inflammation gradually spread, attacked the lip, and then ex- 
tended to the nose, which became red, swollen, and finally 
ulcerated. 

It will be unnecessary to go further into the details of the 
case : it is sufficient to say, that, in the course of eighteen 

months, all the 
textures of the 
nose were succes- 
sively attacked, 
and finally de- 
stroyed. Subse- 
quently, cicatri- 
zation took place ; 
leaving the pa- 
tient in the state 
in which I saw 
him, six months 
after his recovery 
from the disease. 
At this period, 
liaving accidently 
come across a de- 
scription of the 
Taliacotian oper- 
ation in an old 
magazine, he was 
desirous of know- 
ing whether any thing of a similar kind could be done to remedy 
his frightful deformity. The following was his state as he ap- 
peared on the first examination : — 

The nose, as already stated, was completely destroyed, leav- 
ing in the place it originally occupied an opening about an inch 
in diameter, bordered by a firm cicatrice ; the septum of the 
nostrils was gone, and the two nasal cavities thrown into one ; 
externally a small cicatrix descended from the lower and left 
edge of this opening to the angle of the mouth. In the course 




ff 



rJilXOPLASTIC OPERATIOXS. 21 

of the disease the four front teeth had been lost, which, to- 
gether with the absorption of the alveolar processes, had caused 
the upper lip to sink much below the level of the lower 
one. An opening existed between the lip and upper jaw, 
through which a probe might be passed from the mouth into the 
nasal cavities. The sense of smell was quite lost ; and he was 
subject to a flow of tears over the face, arising undoubtedly from 
the too sudden contact of the air with the lachrymal ducts. 

A thorough examination of his case having been made, and 
finding there was no obstacle to the possibility of a successful 
operation, its difficulties were distinctly stated to him, — the im- 
probability of its succeeding so as to restore the organ in such a 
manner that the deformity should not be known ; that the new 
nose might become very much flattened, and, perhaps, on the 
appearance of cold weather, gangrene might take place ; and, 
finally, that even his life might be endangered by it. I felt it 
my duty to state the case plainly, having seen all these accidents 
occur abroad from the operation ; in two cases death being the 
consequence, from severe erysipelatous inflanmiation of the 
scalp. 

Xotwithstanding all these objections, he decided to incur any 
risk which would give him the least chance of having the defor- 
mity under which he labored obviated. It was thought expe- 
dient to delay the operation a few Aveeks, in order to prepare 
him by a course of diet and regimen. At the end of six weeks, 
as he still persisted in the determination of having it performed, 
preparations were made to do it at once, since, on account of 
the approach of cold weather, no time was to be spared. 

The preparations having been made, the operation was per- 
formed on the 7th of September. A piece of pasteboard, 
cut in the shape of the letter Y, that is, of a triangular form, 
and with a projection from its base corresponding to the columna 
of the nose, was placed upon the forehead, and a trace made 
around it with the nitrate of silver, which was used in preference 
to ink, as recommended by Lisfranc, in order that it might not 
be effiiced by the blood. A trace was also made around the 
opening of the nasal fossa, at the points where it Avould be 
necessary to remove the integuments for planting the new skin 



22 THE FACE. 

taken from the forehead. This was done on the night previous, 
in order to prevent any undue delay on the day of the ope- 
ration. 

All unnecessary articles of clothing having been removed, the 
patient was placed on a table in a recumbent position, his face 
towards the window, and the operator behind, so as to have the 
full command of the head. The traces made by the nitrate of 
silver were about two-thirds of an inch apart between the eye- 
brows ; each side of the triangular portion of skin was three 
inches and a quarter in length, with a base of three and a half 
inches ; and the projection for the columna of the nose, which 
was to be taken entirely from the scalp, previously shaved, was 
an inch and a half long, and two-thirds of an inch wide. 

The head being firmly supported by two assistants, the in- 
cision was commenced between the eyebrows, and the flap of 
skin dissected up so as to isolate it entirely from the skin 
of the forehead, except where, for the purpose of nutrition, it 
was left adherent at the root of the nose. The incision on the 
left side, between the eyebrows, was extended a little farther 
down than on the right, to facilitate the twisting of the flap. 
This included the skin, subcutaneous cellular tissue, and a por- 
tion of the occipito-frontalis muscle ; care being taken not to 
raise the periosteum, from fear of necrosis. 

The flap thus dissected, and twisted round to the left side, was 
carefully wrapped in a compress of linen cloth ; and, before the 
operation was proceeded with, attention was given to diminish- 
ing the large wound made in the scalp. Little hemorrhage had 
taken place ; and the temporal arteries, which had been cut, very 
soon retracted, and ceased bleeding. The angles of the wound 
were first brought together by the twisted suture, two pins being 
employed on either side. Its edges between the eyebrows were 
also approximated in a similar manner : by this means the wound 
in the forehead was diminished at once to less than half its origi- 
nal size ; it was still farther reduced by the use of a few strips of 
adhesive plaster, and a little scraped lint filled up the remainder 
of the wound. Lint sj^read with cerate was applied over the 
whole surface, a compress, and the whole secured by a bandage 
round the head. 



EHIXOPLASTIC OPERATIONS. 23 

The next object was to fix the borrowed skin in its place. In 
order to do this, it was necessary to freshen the borders around 
the opening of the nasal fossa, the traces of which, as stated 
above, had been previously made with nitrate of silver. For 
this purpose, a short narrow knife, somewhat similar to a cataract 
knife, was used, and a strip of integument, a third of an inch in 
breadth, removed, including all that portion which had been 
indurated during the cicatrization of the ulcerations. The knife 
was also passed between the lip and upper jaw, in which exist- 
ed, as before stated, an opening large enough to pass a probe ; 
and the adhesions between the two, for the space of an inch, 
entirely cut away. This was done for the double purpose of 
giving the columna of the nose a more deep and firm adhesion, 
and, in the inflammation which would subsequently ensue, to 
close up the unnatural communication between the mouth and 
nasal cavity. 

The flap was now brought down into its place, its angles a 
little rounded with the scissors, the better to simulate the ala3 
of the nose, and the whole secured in its place by pins, and 
points of the interrupted suture. From that portion of the skin 
which Avas to form the columna of the nose, the epidermic side 
was pared, so that it might form an adhesion, not only under- 
neath to the jaw, but on its sides, to the quadrangular wound 
made for it in the upper lip. 

Scraped lint was now placed under the ends of the pins, and 
a strip of oiled lint introduced into each nostril, to prevent 
adhesion ; another strip was placed upon the nose to preserve its 
temperature. The dressings were secured by a band of adhesive 
plaster, fixed to the forehead above, and partially divided in the 
middle, so that it might descend on each side of the nose to 
the lip. 

During the whole of this long and painful operation, the pa- 
tient kept up his courage, and not a cry was uttered, nor the 
least struggle made that could at all impede the motions of the 
operator. Xot much blood was lost, and his strength was so 
little exhausted that he was able to run up stairs to his chamber. 
He was ordered to go to bed immediately, to keep perfectly 
quiet, and a watcher left with him, who had directions, in case 



24 THE FACE. 

of his falling asleep, to prevent him from either rolling over on 
his side, or raising his hand to the nose, so as to derange the 
dressing; also, to wake him immediately should he breathe 
through the nose. To have arrow-root, or gruel and lemonade, 
for nourishment. 

On visiting him in the afternoon, he was found comfortable ; 
the new nose was warm, and had bled a little from the edges 
which formed the nostrils, both showing that the circulation was 
not at all impeded. 

Sept. 10th. Passed a good night, slept well, pulse seventy- 
nine, complains of no pain ; the nose of about the natural tem- 
perature. A piece of cork was confined between the teeth, so as 
to keep the mouth open, and prevent him from breathing through 
the nose during sleep. The introduction of the cork proved 
successful. 

12th. The first dressing took place four days after the opera- 
tion, and the following was found to be the state of the parts : — 

The dressings on the forehead, after being well soaked, were 
•first removed. The ano-les of the wound were found to have 
united throughout, so that two of the pins were at once dispensed 
with. Union had also taken place in its lower part, just above 
and between the eyebrows : the remainder of the wound, that is, 
its central part, in which union by the first intention could not 
take place, was suppurating well, and filled with healthy granu- 
lations. 

Upon removing the lint from the nose, it was found that en- 
tire union had taken place on both sides. The alae and the lower 
edges could not easily be seen without making use of too much 
violence. The columna was curved inwards, and the sutures 
concealed. The nose was of the natural color and temperature, 
and the circulation through it seemed uninterrupted. 

Two strips of lint, dipped in oil, were laid over the cicatrix 
on each side of the nose, and no other dressings used. The 
patient was allowed to sit up a little, and to take any article of 
liquid food he might fancy. 

On the 13th he was quite as well, with the exception of a 
little oedema of the upper eyelids, arising, undoubtedly, from the 
pressure of the bandages and other dressings on the forehead. 



RHINOPLASTIC OPERATIONS. 



25 



One of the pins was removed from the forehead on the 13th ; 
and another, the only remaining one, on the following day. 
The dossils of lint which had been placed in the nostrils still 
remained there, firmly caked in. These were not removed until 
the 16th, when their places were supplied by two pieces of hol- 
low sound. 

On the 14th, a quantity of hair began to appear on that por- 
tion of the skin forming the columna of the nose, which, from 
time to time, re- 
quired to be re- 
moved. He was 
put upon a nour- 
ishing diet, with 
the caution to use 
the jaws as little 
as possible. He 
stated that occa- 
sionally, when he 
swallowed, he had 
a sensation as 
though he would 



'^ swallow 
nose." 
15th 



hi; 




The re- "/ 
maining pins were 
removed from the 
side of the nose, 
and the two su- 
tures which con- 
fined the alai ; 

and on the 17th, ten days after the operation, the two ligatures 
which confined the columna in its place were also removed. 

At this period, the state of the parts was as follows: The 
wound in the forehead had diminished to a third its original size ; 
and the small triangular space which remained, together with 
that portion of the scalp from whicli the columna of the nose 
had been taken, was filled with licalthy granulations. From 
the wound to the root of the nose was a linear cicatrix nearly 



26 THE FACE. 



two inches in length, and continuous with the cicatrix on the left 
side. Adhesion of the integuments had taken place on both 
sides of the nose : at the right ala, however, the union was 
not quite so perfect as at the left ; that is to say, the whole 
thickness of the skin did not appear to have united. To assist 
the union, the skin of the face which lay under it was slightly 
scarified with the point of a knife. 

The columna was a little curved, and its edges had retracted 
inwards upon themselves. The inside of the nose was suppura- 
ting well ; and, at its upper part, adhesion seemed to have taken 
place between the two bleeding surfaces which had been op- 
posed to each other. The tip of the nose was well defined, and 
its edges were curved inwards, so as to simulate the natural 
appearance of the alae ; and just above the al^e, apparently from 
atmospheric pressure, a depression was taking place, forming 
their superior boundary. This was assisted by the patient 
making an occasional pressure with his fingers at these points. 
He felt well, had a good appetite, and sat up all day. He 
breathed freely through the tubes placed in the nostrils, which 
required to be removed daily, in order to clear out obstructions. 

At the end of a month, the wound in the forehead had con- 
tracted to about a quarter of its original size ; adhesion of the 
nose was perfect at all points ; the nostrils were regularly round- 
ed, and simulated well the natural contour ; the tip of the nose 
was well preserved, and the curve from its root to the end of 
the orfi'an was re ovular. 

In six weeks, he was able to go out ; but, as the weather be- 
came cold, he was advised to confine himself to the house, 
since cold evidently had a very great effect in retarding cicatri- 
zation. By reference to the second figure, a pretty correct idea 
will be formed of the state of things six weeks after the opera- 
tion. 

At the end of two months, it was thought time to proceed to 
the second operation, which was required to remove the twist 
at the root of the nose. Underneath the pedicle which con- 
nected the nose with the forehead, a small portion of sound 
skin remained ; and, of course, no adhesion had taken place be- 
tween this portion and the pedicle lying over it. The method 



RHINOPLASTIC OPERATIONS. 27 

usually adopted by operators has been to cut the pedicle, after 
the nose has united sufficiently to justify its separation from the 
source of nutrition, and to fix it down at the root of the nose, 
in a transverse incision made for it at that point. 

To this method there are some serious objections. First, the 
danger of inflammation in separating the pedicle ; second, of 
slouo^hino' of the or^ran, on dividino^ its vascular connections ; 
and, lastly, the very perceptible transverse cicatrix which re- 
mains. The course resorted to in the present case is liable 
to none of these objectians, except perhaps the first one, in 
which the danger is much diminished. 

This was as follows : An incision was made, commencing 
near the internal angle of the eye, and extending to that part of 
the base of the nose where adhesion had not taken place ; a cor- 
responding incision was also made on the pedicle. The skin 
being dissected up, the wrinkle in the integument at the upper 
anorle of the wound was removed : the edoes were then brous^ht 

O CO 

together by sutures. Union took place, throughout, by the 
first intention. 

Four months after the operation, he was entirely well. There 
was no secretion from the nostrils ; and, on looking into those 
cavities, a new skin was found to line them throughout. The 
nose itself gradually contracted, so that, first by the shrinking 
of the integuments, and subsequently from suppuration, it de- 
creased to about two-thirds the size of the flap which was 
taken from the forehead. Contraction also took place in its lon- 
gitudinal axis. The nose was much improved, when the four 
front teeth, which had been lost, were replaced by the dentist, 
which brought out the under lip, and at the same time raised 
the tip of the organ. The cicatrix in the forehead became very 
small, and s^raduallv assumed the color of the surroundins^ intes^- 
uments ; the scalp from which the columna was taken was lost in 
the hair; the nose was quite firm, of a good form, and the 
cicatrix on each side scarcely perceptible. At the root, on 
the left side, and at that portion which formed the pedicle, a 
small fissure remained, which was concealed by a strip of court- 
plaster. 

His health had never been better, his sense of smell gradually 



28 THE FACE. 

returned, and the tears resumed their natural channel ; and he, 
as well as his friends, congratulated themselves, both on the 
moral and physical effects of the operation. 

At the end of three years, no sensible alteration had taken 
place in the restored part. The shape of the nose was perfectly 
preserved ; and there was none of that flattening which has usu- 
ally been brought forward, by the opponents of this operation, 
as one of the greatest objections to be preferred against it. In 
those cases where this finally occurs, it almost universally arises 
from the flap, in the first place, being too small ; and, the inter- 
nal surfaces not being well opposed, adhesion fails, and, as soon 
as the swelling subsides, the nose is left fiat and deformed. 

In the present instance, the operation was almost a new life 
to the subject of it, restoring him to the society of his friends, 
and enabling him to establish himself in business. 

Remarks. — One of the greatest difficulties of the operation 
was the management of the sutures to close the wound in the 
forehead, and to confine the new nose in its situation. 

At that part of the fiap which was to simulate the alas, — as 
it was necessary that the integument should be directed inwards, 
— pins, of course, could not be used; and here a plan recom- 
mended by M. Labat was adopted, which was followed by 
partial success. A thread being passed, first through the integ- 
ument of the face, and then through the flap, at about two lines 
distant from their edges, the ligature was so tied as to produce 
a fold ; and, the better to effect this, a small cylinder of adhe- 
sive plaster, was confined under the threads, so as to make a 
strong compression on the wound, and to force the edges into 
their places. This succeeded completely on one side ; on the 
other, union was not so entire. 

During the whole of the treatment, it was necessary to keep 
the nostrils distended by small tubes. The substance which 
answered best for this purpose was the barrel of a quill, the end 
which remained in the nose being stopped up with melted sealing- 
wax, and a small aperture cut in the side, through which the air 
could pass freely. The tendency to contraction was very great, 
so that, at one period, the tubes being left out during the night, 
it required considerable force to replace them. 



RHINOPLASTIC OPERATIONS. 29 

As the new nose was formed entirely of skin, it will per- 
haps be supposed, that the integuments composing it were 
flaccid, and the form of it easily destroyed. This, however, 
from reasons easily appreciable, was not the case. The integu- 
ments of the scalp being naturally of great thickness, by the 
suppuration which took place from the inner side, assumed a 
firmness almost similar to fibro-cartilage ; and, at the root of 
the nose, the internal surfaces coming in contact, contracted 
adhesions, so as to make it perfectly solid at that part. The 
columna also formed a round and solid pillar to support the tip 
of the nose. 

Great precautions had been taken to guard against exposure 
to cold, which, by stopping the circulation, might at once de- 
feat the whole object of the operation. As soon, hoAvever, as 
adhesion had taken place, it was perceived that no danger from 
this source was to be apprehended ; and, although during the 
winter he slept in a room in which water frequently froze, and 
was repeatedly exposed during some of the coldest days, the 
temperature of the organ was never greatly diminished. 

The cicatrization of the wound in the forehead was retarded 
by the cold weather, and less than half the time would have 
been required, had the operation been performed during a 
warmer season. When it had diminished to a small size, and 
cicatrization — as frequently is the case in the filling-up of large 
wounds — seemed to have been arrested, great benefit was found 
from the use of an ointment composed of six drops of creosote 
to an ounce of simple ointment. On the application of this to 
the wound, the effects were at once apparent. A small pellicle 
formed over its whole surface, which was shortly replaced by a 
firm, consistent cicatrix. 

In one or two cases operated upon by Dieffenbach, much 
swelling took place in the new-formed nose the day after the 
operation, arising from the difficulty with which the blood was 
conducted off by the veins. In one case, the nose became so 
enormously distended that it was feared the adhesions would be 
entirely destroyed ; and it was only by the repeated application 
of leeches, seventy or eighty being employed in the course of 
forty-eight hours, that this was avoided. In the present case, 



30 THE FACE. 

from the extension given to the incision on the left side, care 
being taken that traction should not be made too forcibly on the 
part, so as to compress the pedicle at its base, the circulation 
was, from the first, unobstructed. 

This case, having been the first successful one in this coun- 
try, has been more fully related. It must be remembered that 
it was done before the days of ether, which greatly facilitated 
subsequent tedious operations of this description. 

Case XIV. — Rhinoplastic Operation, hy the Method of 
Taliacotius. — This was a case of lupus of fifteen years' stand- 
ing. The commencement was by a spot on the very tip of 
the nose, which gradually extended, becoming finally of a livid 
red color, and having its surface covered by numerous elevations 
of a tubercular appearance. In his ordinary state of health, and 
when perfectly quiet, the only sensation in the affected part was 
that of heat and itchino^ : but, on the slio^htest derano^ement of 
the system, and upon any extraordinary exertion, ^an intense 
burning and stinging was felt, not only in the nose itself, but 
in the surrounding integuments ; and often so insupportable as 
to oblige him to desist from his work, and have recourse to 
cold applications, for temporary relief. He submitted to a great 
variety of treatment, continued for a number of years, but with- 
out the slightest benefit. A caustic had been applied, a year 
before, which destroyed a part of the skin, and the subjacent 
cartilage ; most of the disease remaining undisturbed. 

He came to Boston, determined to have the affected part re- 
moved, and the loss of substance supplied by the Taliacotian 
operation. At this time, the nose had a very pinched appear- 
ance, the skin being of an intense red towards the tip, and bav- 
ins: in its substance a number of hard, tubercular bodies. A 
sliofht redness extended over the ala nasi of the ris^ht side. In 
the centre was a depression, and loss of substance, where the 
caustic had been used. 

The operation was performed on the 8th of April, 1840. The 
disease, which extended up as far as the nasal bones, was very 
carefully removed ; and the cartilages below, not destroyed by 
the caustic, were found to be in a perfectly healthy state. The 



RHINOPLASTIC OPERATIONS. 31 

dimensions of the flap were carefully taken, and marked out on 
the fore-arm. The traces were made on the radial side of the 
left arm, about two inches from the styloid process of the ra- 
dius. This flap was dissected up, including with the skin, the 
sub-cutaneous cellular membrane, and was secured in its new 
situation, in contact with the face, by five sutures ; the arm being 
firmly fixed in this position by appropriate bandages. Nour- 
ishment was to be taken through an elastic tube ; the mouth 
being so covered up as to prevent the direct introduction of 
food. He was placed in bed, and supported in a sitting pos- 
ture by a common bed-chair. 

On the following day, the 9th, there was some appearance of 
erysipelatous inflammation on the bridge of the nose : he had 
been pretty quiet, and had slept a little, but required constant 
watching to prevent him from slipping down and doubling him- 
self up in the bed. He complained much of a want of solid 
sujDport to the elbow ; and therefore a wooden apparatus was 
constructed, and placed across the bed, which served as a 
firm resting-place for the arm, and enabled him to maintain 
more easily the proper position. The pulse was sixty ; and, 
throughout the whole period of his confinement, it remained 
below the ordinary standard. On the 10th, he complained less 
of his arm, but was exceedingly restless. During the day, he 
was removed to an easy-chair, and the change afforded great 
relief. 

The state of things varied little from that already described, 
until the fifth day, the period appointed for separating the con- 
nection between the arm and face. On this day, the base of the 
flap was divided : a perfect adhesion had taken place. 

The wound in the arm was dressed, and a small portion of the 
skin which projected bound down in its place by adhesive straps. 
The irregular portions of skin attached to the nose were re- 
moved ; and a slight compression made on the edges around the 
nostrils, with strips of adhesive plaster. 

The arm, on being relieved from its confinement, was not so 
painful as might have been expected : there was an almost 
entire loss of power in the flexor muscles. In the course of a 
few days, however, it regained its healthy state of feeling and 
motion. 



32 THE FACE. 

By the 20th of April, the newly transplanted skin had con- 
tracted to nearly the natural size ; the line of union with the skin 
of the nose was perfectly lineal ; all the abrupt and useless por- 
tions of skin on the lower edge of the nose had sloughed off, 
leaving a perfectly even and rounded edge to the nostrils. 

On the 23d, I was surprised, on removing the green cot 
which covered the dressings, to find that the whole cuticle of the 
restored part had peeled off, leaving the surface quite raw, and 
covered by the green coloring-matter of the silk. This at first 
seemed likely to prolong the period of recovery, but it proved 
of material benefit : a slight suppuration commenced, which 
brought down the skin to a natural thickness, and rounded 
off, in the most perfect manner, every inequality ; and seemed 
also to melt the skin into the adjacent integuments, so as almost 
to destroy the traces of the line of union. A new cuticle rap- 
idly formed ; and, by the end of the month, he was quite well. 

Subsequently, having exposed himself to the sun, he was 
troubled with itching in the right ala of the nose, where a slight 
redness remained. He came to me, very desirous to have the 
skin of this part at once removed. He was anxious that the ex- 
periment should be tried of cutting a piece of skin from the 
arm, and immediately placing it in the wound, to supply the loss 
of substance. Although I did not consider this part of the 
operation necessary, I yielded to his desire, and made the at- 
tempt. The diseased skin was removed, and its place supplied 
by a piece from the fore-arm, kept in place by lint moistened 
in blood. On removing the dressing, at the end of four days, 
a good union had taken place. 

It will be perceived, that, in this case, the old operation, as 
performed by Taliacotius, of taking the desired integument from 
another part of the body, was preferred to the Indian method, 
in which the skin is borrowed from the forehead and hairy scalp. 
The reasons are perfectly obvious. The loss of substance to be 
supplied was small. By the course resorted to, a scar on the 
forehead was avoided ; and that on the arm was of no impor- 
tance. 

The operation was not precisely that of the Italian surgeon. 
Taliacotius preferred taking the skin from the arm near the 



RHINOPLASTIC OPERATIONS. 



33 



insertion of the deltoid muscle ; and, by adopting this method, 
the limb can be much more securely fixed in contact with the 
head. In the present case, the patient being a muscular man, the 
arm could only be brought to that position with great difficulty. 

It also differed from that of Taliacotius, in the early separa- 
tion of the transplanted skin from its connection with the arm, 
on the fifth instead of the fourteenth or fifteenth day ; and, as 
the principal objection to his method is the position in which 
the arm is so long and painfully confined, this is certainly a 
very important consideration. The Italian surgeon raised the 
flap gradually, allowing it to suppurate and contract. The 
most important point, however, the adhesive process, must by 
this means have been rendered much less certain. 

The accompanying print will afford some idea of the position 
of the patient while the arm was confined to the face. 




Case XV. — Rhinoplastic Operation. — A young woman, 
27 years old, from jNIaine, applied to me in 1839, having lost 



34 THE FACE. 

her nose in the following manner : Sixteen months before, hav- 
ing a wart on her nose, she was induced by her friends to apply 
for advice to one of those quacks styled cancer doctors, who 
easily persuaded her that the affection was of a cancerous na- 
ture. A caustic was used, which produced so great a degree 
of inflammation as to alarm her, and oblisre her ao-ain to have 
recourse to him. His answer was that the application should 
be continued, not only to the wart itself, but over the adjacent 
parts, " so that none of the roots of the disease might escape." 
It was therefore persevered in ; and so effectually, that, at the 
end of a fortnight, all the flesh of the nose sloughed off, leav- 
ing her in a most deplorable condition. On re-application to 
the quack as to what was to be done under these circum- 
stances, he assured her that it was a most happy termination 
of the disease, wliich, by these means, had been wholly eradi- 
cated ; and that the nose, in the course of time, would grow 
out again, and be perfectly restored. 

These assurances, as may well be conceived, were not des- 
tined to be realized : the edges of the wound gradually cica- 
trized, leaving her in the state in which I saw her sixteen months 
after. 

Her condition was much as follows : The tip of the nose, 
together with the alee nasi and corresponding portion of the 
septum, w^as entirely destroyed, leaving the nasal passages ex- 
posed : the ossa nasi, with a small portion of skin covering 
them, remained entire, their edges being lined with a firm and 
somewhat vascular cicatrix. In other respects, she was a good- 
looking woman ; and her health as little disturbed as could have 
been expected. 

The operation was done on the 17th November of the same 
year. The patient was placed in a recumbent position, with her 
head well supported by pillows. The dimensions of the flap 
were traced on the forehead, nearly one-third larger than was 
necessary for the formation of the new nose. This was dis- 
sected up, and every precaution taken to leave the pedicle of skin 
between the eyebrows sufficiently large to allow free vascular 
communication. Care was also taken to leave the angular 
arteries unwounded, as upon these depended the principal means 



RHIXOPLASTIC OPEEATIOXS. 35 

of support to the flap. Before proceeding farther, the edges of 
the wound in the forehead were approximated by the twisted 
suture. This was faciUtated by the incision in the scalp being 
prolonged to a pyramidal form. 

The cicatrix covering the nasal bones was now removed, the 
flap twisted round, and secured in its place. The strip which was 
to form the columna of the nose was deeply implanted in the 
uj^per lip ; the whole was supported by small strips of adhesive 
plaster, and covered with lint, to preserve, as much as possible, 
its temperature ; small tubes were introduced into each nostril. 

The patient was directed to keep in bed, to remain perfectly 
still, and to breathe through the mouth. 

On the following day, the nose was swollen ; pulse seventy- 
two ; she w^as rather restless. On the 21st. the sutures were 
removed ; entu-e union had taken place. The sensation was 
nearly natural, and, as in the previous case, but slightly referred 
to the part from which the skin had been transplanted. The 
form of the nose was o:ood, with a reo-ular curved outline : the 
al^e nasi, also, were well defined. The nostrils were kept open 
by means of the small tubes, which were removed daily, and 
cleansed. The wound in the forehead was dressed daily with 
creosote ointment. She also derived much comfort from a creo- 
sote gargle, for purifying the mouth. On the columna, which 
was taken from the scalp, hair continued to grow : but was 
easily removed by scissors, so as to be scarcely perceptible. 

From this time, she gradually gained in strength, and was 
able, in a few days, to sit up. The wound in the forehead 
slowly cicatrized, and the nose assumed a more natural appear- 
ance. In the following spring, I performed the comparatively 
trifling operation which was required for confining the pedicle 
in its place. The cicatrix of the forehead was then quite firm, 
and easily concealed by the hair. 

The operation, in this case, with some slight exceptions, 
resembled the first. In the first operation, the twisted suture 
was used for confining the new nose in its place. In the present 
instance, however, the interrupted suture Avas substituted, and 
answered a much better purpose: the points of ulceration, on 
the removal of the threads, being less. 



36 THE FACE. 

Case XVI. — Rhinoplastic Operation, by the Method of 
Taliacotiiis. — In this case, the operation was performed ac- 
cording to the method recommended by Taliacotius, modified, 
however, by the experience which modern practice has suggest- 
ed ; the skin being borrowed from over the biceps muscle, as in 
the Tahacotian operation. It is more interesting, from its being, 
so far as we know, the only one which had been successfully 
performed by this method for twenty years previous, the sepa- 
ration of the flap being made at an earlier period than in any 
case on record. 

The union was thought sufficiently perfect at the end of sev- 
enty-two hours, or three days, to warrant the separation of the 
new flap. In earlier cases, reported by Graefe, Delpeck, and 
others, ten to fourteen days were thought necessary to secure 
union. The advantage of this early division of the parts will 
be easily perceived. The preference of this method is, that no 
scar is left on the forehead. At the same time, it must be 
acknowledged, that the skin of the arm does not possess sufficient 
firmness or elasticity for the construction of the nose, where the 
substructure, such as the bones and cartilages, have been de- 
stroyed. 

The patient was a female 30 years old. Having a warty 
excrescence on the nose, she applied, as in the previous case, to 
a quack, who enjoyed notoriety in the treatment of cancers, and 
who, as usual, at once informed her that the disease was cancer- 
ous, and advised its removal. A caustic was applied, but "so 
badly managed, that not only the disease, but a portion of the 
nose also, was destroyed, leaving the unfortunate subject in a 
most distressing situation. 

It looked exactly as if the nose had been neatly excised : 
the skin, a portion of the cartilage forming the septum nasi, and 
about one- third of the columna, were wanting. The nasal cavi- 
ties were exposed, and the deformity produced of a very striking 
and disagreeable character. 

The loss to be supplied was not sufficient to justify a resort 
to the Indian method, especially as the lady was not so stout 
as to render that of Taliacotius insupportable. 

I advised her to return home, and to have a bandage made 



RHINOPLASTIC OPERATIONS. 



37 




such as is described and depicted in the work of Taliacotius, 
and to exercise herself daily for a few weeks in keeping the 
arm in contact with the face, in the position which it would 
be requisite to maintain after the operation. The operation 
was performed on the 21st of October, 1840, in the presence 
of Dr. Ed. Eeynolds, Dr. S. D. Townsend, Dr. H. B. Inches, 
and a number of other medical gentlemen. 

The cicatrix covering the edge of the nostrils w^as first re- 
moved, and the apex of the septum and columna nasi made into 
a raw surface. A flap, nearly double the size required, was now 
dissected out from over the upper part of the biceps muscle of 
the right arm, its base, w^hich presented downwards, being left 
attached. The bleeding having ceased, and the flajD having con- 
tracted nearly one-half, the arm was brought up to the face, 
and the edges of the flap confined in contact with the raw sur- 
face of the nose by six sutures. The bandage of Taliacotius, 



38 THE FACE. 

of which the accompanying wood-cut gives a good idea, as well 
as of the general appearance and position of the patient, was 
now applied, and served to maintain the arm immovably fixed in 
contact with the head.* The whole of this painful operation, 
which was before the days of ether, was supported with the 
most determined fortitude. 

Oct. 2 2d. Since yesterday she has remained in an arm-chair, 
preferring the sitting posture as the most comfortable, both 
for breathing and for taking nourishment. For an hour or 
two after the operation, the arm was quite numb, from its con- 
strained position and the pressure of the bandages. This gradu- 
ally changed to a painful sensation. 

23d. She complains to-day of severe pain in the wrist, 
which was very soon relieved by wetting the bandages with 
laudanum; and almost immediately after each application, 
she was composed to sleep. The bandages were relaxed a little 
from being wet, but not so much as to do injury. 

24th. To-day, seventy-two hours after the operation, I pro- 
ceeded, in presence of a number of medical gentlemen, to divide 
the pedicle, and release the arm from its painful position. On 
first letting it down, it appeared quite paralyzed ; but by gentle 
friction the power of motion and sensation was gradually re- 
stored. 

A perfect adhesion had taken place between the new flap and 
the right side of the nose. On the other side, the skin was so 
wrinkled up from the pressure of the head, that it was not pos- 
sible to determine what was the state of union. Out of the new 
flap a pedicle was now shaped, to serve for the completion of 
the columna, and was confined m contact with what remained 
of the old one by a single suture. 

The patient was in good spirits, and appeared but little 
fatigued from the painful position in which she had been confined 
for such a length of time. Her sufferings had certainly been 



* I am indebted to the kindness of my friend Dr. Inches for a copy of the 
original foHo edition of Tahacotius, bearing the date of 1597, from which this 
wood-cutis copied. This very rare and curious work was obtained, with much 
difficulty, in Italy ; and but few copies are to be found in preservation at the 
present day. 



RHIXOPLASTIC OPERATIONS. 39 

greatly alleviated by the possibility of being able to move about 
the room Avithout interfering with the adhesiye process, owing 
to the perfect retentive power of the bandages. 

25th. Quite comfortable ; the tip of the nose looked well ; 
the edges on one side somewhat livid, but, on being touched 
with the knife, bled freely ; a portion of the new columna in a 
sloughing state. 

Xov. 11th. A small piece of the skin which formed the 
septum having sloughed, tlie remainder has settled down, and 
at present is firmly united in its situation. The nose has a 
good shape, but is still a little swollen. 

Dec. 12th. She returned home well. Her nose had en- 
tirely healed ; its form was good ; the tip was slightly turned 
up, and the whole organ a little shortened when compared with 
its original dimensions, but was still agreeable, and presented 
nothing remarkable to a casual observer ; the line of union had 
so melted doAvn into the surrounding parts as to be scarcely 
perceptible. 

Case XYII. — Mrs. F., 30 years of age, was treated by 
me, for a number of years, at my house and at the Hospital, 
for an ulceration of the nose looking like lupus, but probably 
specific, which she says first attacked her breast. The disease 
of the breast commenced eight years before. The whole nose 
was attacked and destroyed ; the vomer, the left turbinated bone, 
and the orbitar process of the superior maxillary. The whole 
posterior nares was exposed, and the opening of the Eusta- 
chian tubes distinctly visible. The palate was thrown up in 
the act of swallowing. The left maxillary sinus was quite 
open on the inner side. The destruction of parts was much 
greater than I have ever before seen, and the opening on the 
face larger. A cure w^as finally effected by the persevering use 
of the iodide of potassium. AVhen the operation was performed, 
— March 28, 1855, — the ulcer had been healed up for eight 
months. The flap was taken from the forehead, as in two of 
the previous cases, being somewhat modified in order to cover 
the irregular aperture. The part to form the septum was taken 
from the scalp, previously shaved, and was an inch and a half 



40 THE FACE. 

long. It was twisted around, and nicely adjusted in its place 
with sutures ; the edges of the skin on the face having been 
made raw. She was much depressed by the operation ; but 
the skin united well, and she ultimately recovered, after the 
usual protracted treatment which these cases require, with a 
most excellent nose, and a very slight scar on the forehead. A 
small aperture was allowed to remain at the left side of the 
nose, at her own request, to facilitate the removal of the long 
black hair, which continued to grow from the septum, in a 
direction down the throat, causing considerable irritation. The 
aperture referred to was covered with court-plaster. 

This case, as most of the others, has a touch of romance about 
its subsequent history. She called on me some years after, and 
said that her good looks had been so far restored, that she had 
attracted the attention of a soldier, and had been a second time 
married. The marriage, however, turned out an unfortunate 
one ; as I have lately learned from my brother, Mr. J. S. War- 
ren (who was called on to administer charity to her), that her 
husband, in a fit of intoxication, had threatened her life in the 
middle of the night, and so alarmed her as to make her jump 
from a window in the third story, which nearly terminated her 
career. 

Case XYIII. — A gentleman, 49 years of age, a tall, hand- 
some, and powerful man, wrote to me in the early part of the 
year 1857, to know if any thing could be done to restore his 
nose, the greater part of which he had cut off in a temporary fit 
of insanity some years before. I described to him the nature of 
the operation, as being a very painful and fatiguing one, and 
requiring a good part of the skin of the forehead to be used in 
the manufacture. I represented the very worst side of the 
picture to him, fearing a person of his situation and appearance 
would hardly be satisfied with the rough substitute made for 
one of the most important features of the face, however suc- 
cessful the surgeon might be. He answered me, that he was 
determined, at any risk, to have the operation done ; and, in 
the month of October, he came to my house, having made a 
journey of from one to two thousand miles. 



RHmOPLASTIC OPERATIONS. 41 

After an examination of the case, and finding how much of 
the skin of the forehead it would take to supply the lost organ, 
I felt great hesitation at the undertaking. He stated, however, 
that he had come a great distance for this purpose, that he placed 
himself fully under my direction, and would wait any length of 
time till I had fully matured my plans. 

Having finally determined to do the operation, it w^as per- 
formed on Oct. 25th, with the assistance of Drs. Briggs, Hay- 
ward, and Slade. The remains of the old nose were first slit 
open in the centre ; and the lateral flaps, which had partially 
caved in, were dissected up from their adhesions. A large tri- 
angular flap of skin, involving nearly the whole forehead, was 
now dissected up, with a small column, taken from the hairy 
scalp, to serve for the septum of the nose. This flap was en- 
veloped in a cloth until the wound in the forehead had been 
dressed. The operation otherwise was conducted as described 
in the previous cases. 

From the turgid state of the vessels of the face, the operation 
was necessarily a very bloody one. For this reason, and from 
the necessary delays in determining the size of the flaps, and 
fitting them nicely in their places, it lasted nearly three hours. 
The patient declined to take ether, and bore the whole of this 
long and painful operation with the most unflinching firmness, . 
so that a bystander could hardly have determined whether the 
surgeon was operating on a living or dead subject. 

He passed a quiet night. The next day his pulse was eighty, 
and he had very little uneasiness in the nose or forehead. On 
the 28th, the forehead was dressed, and all the angles and 
proximate parts connected by sutures found to have united by 
the first intention. 

On the 29th, the new nose was dressed, and the flaps were 
so well united to 'the cheek, that they seemed to have melted 
into it. 

On Nov. 1st, the plugs were removed from the nostrils ; the 
patient was up, and about the room. 

Nov. 22d. He had been out of doors for two weeks in per- 
fect health. The wound in the forehead was healed, leaving in 
the centre a scar scarcely perceptible. The nose looked well, 



42 THE FACE. 

the sensibility was natural, perhaps a little dull, not referred to 
the forehead. The twist in the pedicle had become effaced by 
a most remarkable transposition of the parts ; the scar, which 
originally commenced on the right side, being draAvn over to the 
left by contraction of the tissues. The small apertures which 
remained on this and the opposite side of the pedicle were easily 
obliterated by subsequent manoeuvres. 

The patient was extremely elated by the success of the opera- 
tion, and by the very natural appearance of the substitute. The 
re-action, after this long period of retirement, brought on con- 
siderable excitement of feeling. Notwithstanding my repeated 
precautions, and advice to him to return home, he indulged 
in a very free course of living ; which ultimately terminated in 
an attack of apoplexy, which destroyed him. 

OPEKATIONS FOR THE EESTORATION OF THE LOWER 
EYELID. 

The difficulty of repairing the eversion of the eyelid after 
burns and other accidents attended by destruction of the integu- 
ments is well known. 

Since the introduction of the autoplastic methods for the res- 
toration of lost parts, the transplantation of cutaneous flaps for 
supporting the remains of the everted eyelid has been attended 
with success. The two followino- cases are oiven in illustra- 
tion : — 

Case XIX. — The subject of this was a boy 12 years of age, 
from Weymouth, Mass. When an infant, he was dropped into 
the fire. The consequence was an extensive burn of the left 
side of the face, and a partial destruction of the lower eyelid. 
As the wound in the cheek cicatrized, the remains of the lid 
were completely everted, and the tarsal cartilage with its cilia 
firmly bound down to the lower edge of the orbit. 

The effect of this was a constant epiphora, causing much irri- 
tation of the integuments. From the exposed state of the con- 
junctiva, it had become thickened, having the appearance of 
epidermis ; and the cornea, from exposure to air, presented an 



OPERATIONS ON LOWER EYELID. 43 

opacity which was daily increasing, and threatened destruction 
of vision. Under these circumstances, the following operation 
was performed on the 12tli of June, 1841 : — 

An incision, about an inch and a half in length, was made 
parallel with the commissure of the eyelids, and about two lines 
below the palpebral margin ; and, after a careful dissection, the 
remains of tlie eyelid were separated from the edge of the orbit. 
The dissection was then continued upwards between the tarsal 
cartilage and the conjunctiva, and the connections so far des- 
troyed as to allow the lid .to be restored to its natural position. 
The thickened and diseased subcutaneous cellular membrane 
was then completely removed. 

By the separation of the edges of the skin, a large oval-shaped 
wound now presented, and this was to be filled by a portion of 
skin taken from a neighboring part. To effect this, an incision 
was commenced from the outer angle of the wound, and carried 
in a semicircular direction over the temple, at which point, 
under the hair, was the only portion of sound skin which had 
not suffered from the effects of the burn : an oval flap was here 
dissected out, about one-third larger in size than was required, 
and, having fully retracted, was twisted round and maintained 
in its situation by means of sutures, and a slight pressure exer- 
cised upon it with a roller bandage. Before terminating the 
operation, the thickened conjunctiva, which formed a projection 
beneath the lid, so as to prevent its perfect application to the 
eyeball, was raised up, and entirely removed. 

The termination of this case was quite successful. At the 
end of four days, the dressings were removed, and the adhesion 
of the flap was almost complete ; a slight suppuration only, at 
its inner angle, having occurred. The parts were all much 
swollen. At the end of a week, the pedicle which connected 
the newly transplanted flap to the neighboring parts was divided, 
and bled freely. The patient was sufficiently well in a month 
to return home. 

About three months after, he gave the following account of 
himself: He was able to close the eye perfectly, and the tears 
had resumed their proper channels. The newly formed lid 
seemed to fulfil all its functions, and there was no disposition 



44 THE FACE. 

to eversion. The opacity of the cornea had so far disappeared 
as to be scarcely perceptible. The only circumstance which 
required a remedy was a disposition in the ncAv lid to stand 
out from the eyeball, as if from a swollen state of the conjunc- 
tiva : this was remedied by the repeated application of a pencil 
dipped in sulphuric acid, so as to destroy a narrow strip of the 
conjunctiva. The transplanted skin at first protruded, but 
gradually settled down to the level of the surrounding integu- 
ments. 

Case XX. — The second case was a young lady 19 years 
old. The accident which produced the deformity was very simi- 
lar to the preceding one ; having fallen into the fire when an 
infant, she had been badly burned in the face. From this 
resulted a very extensive cicatrix, affecting nearly the whole 
skin of the face, and in some parts implicating the subcuta- 
neous textures. The left eyelid was drawn down and everted 
at its external angle, leaving the eyeball exposed. From the 
destruction of the inteo^uments of the cheek, the left anMe of 
the mouth was drawn upward in a direction to meet the external 
angle of the eye, there being about an inch and a half distance 
between the two. A large, firm band of indurated and thick- 
ened integument extended from the forehead perpendicularly 
across the brid2:e of the nose. The external edo:e of the rio;ht 
eye was also slightly drawn downward by a cicatrix ; but, the 
cheek of this side ha^dng partially escaped the effects of the 
burn, there was no eversion of the eyelid. The following opera- 
tion was planned and executed on the 7th of November, 1840. 

An incision, two inches in length, commencing on the cheek, 
midway between the eye and upper lip, was carried with a 
semicircular sw^eep in a direction upward and outward towards 
the ear, its convexity being dow^nward. The skin was then dis- 
sected up, both above and below, so as to relieve the traction of 
the integuments in either direction ; and, on this being accom- 
plished, no difficulty was found in restoring the eyelid and angle 
of the mouth to their natural positions. 

From the separation of its lips, the wound on the cheek now 
gaped widely open, being an inch in the perpendicular, and two 



OPEEATIOXS ON LOWER EYELID. 45 

inches in the transverse, diameter ; and tliis was to be filled up 
by borrowed integument. The effects of the burn having pene- 
trated into the muscular substance, it was necessary first to 
remove all the indurated substance covering the floor of the 
wound. A large oval-shaped flap, one-third larger than was 
necessary to fill the Avound, Avas dissected from the temple, 
twisted round, and without difliculty adjusted, and secured in 
its new situation by means of sutures, as in the preceding case. 
The wound on the temple was drawn together by sutures, and 
in a direction to favor the transplanted skin in remedying the 
deformity. 

Thl unseemly cicatrix on the bridge of the nose was now 
completely dissected out. The vessels which were divided during 
the operation were allowed to bleed until they ceased voluntarily, 
it being desirable to avoid ligatures. The wound was dressed 
with graduated compresses, secured by a bandage. Quiet was 
enjoined ; notwithstanding which, from talking, a slight hemor- 
rhage was produced, which partially prevented the union of the 
transplanted flap. 

But little constitutional irritation followed the operation. On 
the fourth day the ^bandage was removed, and two-thirds of the 
flap was found to have united : the inner portion, towards the 
nose, was raised up by a coagulum of blood, and the union at 
this point, of course, defeated. The wound on the temple had, 
in a great measure, united by the first intention. On the sixth 
day, the ligatures were all removed, and the inner portion of the 
flap, which showed a disposition to slough, was cut aw^ay ; the 
wound at this point, where, fortunately, the support was least 
required, being allowed to heal by the second intention. 

At the end of six weeks, the wounds had all healed; and 
she returned home, greatly improved. There was no disposition 
to e version of the eyelid, and its functions were well performed. 
Tlie mouth was also restored to nearly its natural appearance. 
The facial expression was greatly improved by the removal of the 
unsightly band, which projected out over the bridge of the nose. 

The above cases are selected from among a great number 
of similar instances ; the operations of a plastic character about 



46 THE FACE. 

the face being, as a general thing, unusually successful. What- 
ever operation is used for restoring the eyelid or the mouth to 
its position when drawn down by a cicatrix, it is important that 
the integument should be freely dissected up from the subjacent 
parts, so as to allow the eyelid or mouth to be restored to its 
position by bringing the integument on a different plain, as re- 
gards the subjacent parts, from that which it occupied before. 
A simple division of the scar, and allowing the edges to separate, 
even if a flap is introduced, would not remedy the difficulty. 
In the eyelid particularly, the dissections must be very thorough, 
and carried quite up to the edge of the lid. 

During the past year I have operated on two children, a boy 
and a girl, both about 8 years of age, in which the integument 
of the lower lip and entire neck had been destroyed by fire ; 
the mouth being open, and the edge of the lower lip in contact 
with the sternum. In one case, the jaw had been completely 
deformed by the tension, the two middle incisors being some 
distance in front of the lateral ones ; the whole face, in fact, 
with the lower lids, was on a stretch ; and the eyeball was 
strained upwards, in order to allow the patient to see objects in 
front of him. In these cases, by a semicircular cut at the base 
of the scar on the sternum, and subsequent dissection, the head 
was liberated, and restored to its place : the wound being cov- 
ered by skin, slipped along from the sides of the neck, in one 
case ; in the other, two tunnels of skin running beneath the 
scar supplying the requisite integument. In the case of the 
boy, which was the most extreme, it was difficult for him for 
some time to get accustomed to the new position of the head, 
which felt to him as if about to tumble off backwards, the sup- 
port in front being lost. 

The cure of but few of these cases can be completed by a 
single operation ; a series of operations, extending sometimes 
through a number of years, being required, if the destruction of 
the integument is great, and the deformity implicates a number 
of organs. The organs interested in the health and nutrition 
of the patient must be first attended to ; the finishing touches, 
affecting the appearance, being left till a later period. 



EPITHELIAL CANCER AND RODENT ULCER. 47 



EPITHELIAL CANCER AND RODENT ULCER. 

There are three kinds of morbid affections, each accompanied 
with ulceration, and situated upon some portion of the fiice, 
which it is necessary to distinguish from each other, — epithelial 
cancer, lupus, and rodent ulcer. 

Epithelial cancer is generally found upon the skin, and es- 
pecially upon the lower lip, though it is not confined to this 
situation, but occurs upon other portions of the body, as the 
tongue, the scrotum, the labia, around the anus, and even in 
the larynx or pharynx, upon the uterus, and in the bladder. I 
have never seen a case of it in the upper lip. 

At the commencement of the disease, there is noticed a swell- 
ing, with a round or oval hard base ; or a wart, with a pro- 
jecting, dark, dry summit ; or simply a scale of a dark color, 
most generally seen on the cheek, which, after repeated remov- 
als, perhaps through a series of years, ultimately terminates in 
ulceration : this extends, involving the adjacent tissues, till a 
large ulcer is formed, with the edges everted and excavated ; the 
base is reddish, concave, and bleeds easily ; it discharges a thin, 
sanious liquid. 

The different appearances dependent upon the variety of situa- 
tion, or the manner in which the peculiar epithelial cells are 
situated, is fully and minutely described by Paget, who also 
gives a description of the microscopic appearances. 

There is no tendency towards healing ; and, if left to itself, 
the destruction of substance becomes more extensive, the lym- 
phatic glands connected with the diseased part enlarge, finally 
ulcerate, and death is the result. Early excision will usually 
arrest, and sometimes destroy, the disease, though it may return 
in the neio'hborino; tissues. 

In regard to cancer of the lip, the disease is so frequent that 
is is hardly worth while to adduce cases. So far as my expe- 
rience goes, it is more generally situated on the left than on the 
right side ; having its origin in some irritating cause frequently 
repeated, such as the stem of a clay tobacco-pipe, or the passage 
over the lip of the saliva saturated with tobacco, in tobacco- 
chew ers. 



48 / THE FACE. 

I have been mucli struck, in removing cancer of the hp, to 
find how far, in almost every instance, the real cancerous de- 
posit extends beyond the apparent disease on the free surface. 
Too great caution cannot be uro-ed in res^ard to s^ivino; the 
ulcer a wide berth ; and it will be found, on dissection, that 
the sound parts have been seldom sacrificed. 

After removal, it perhaps may be advisable to enjoin on the 
patient a simple and unirritating diet, avoiding animal food, and 
all alcoholic stimulants, for a limited period of time. 

Dr. Walshe says, "There is only one affection which may 
easily be confounded with cancer of the lip ; viz., venereal ulcer- 
ation, with an indurated base. I beheve it will be admitted by 
all persons who have had occasion to observe much of diseases of 
this nature, that it is often impossible to determine, from the 
local characters of the ulceration, whether this be syphilitic or 
cancerous." 

In the cases, however, which I have seen, the chancre was on 
the upper lip instead of the lower, a circumstance which I have 
never met with in regard to cancer. 

Lupus generally appears first upon the nose, or the cheek, 
near the nose, as a small tubercle, yellowish on the summit, and 
reddish around the base. The ulcer which forms is rather more 
superficial than in the preceding variety, with less swelling ; the 
edges are ragged, not indurated, and sometimes everted and 
excavated. Lupus, after ulceration has commenced, is not con- 
fined to the integuments, but may also involve cartilage and 
ligaments, destroying large portions of the face. Sometimes it 
heals spontaneously, though it is then more likely to return in 
the cicatrix ; but, if extirpated by the knife or caustics, it sel- 
dom returns. Cicatrization commences at the circumference. 
The cicatrix is peculiar, usually being crossed by elevated bands, 
and having knobs scattered over its surface, at first quite livid, 
subsequently becoming white. 

The last of the three diseases received from Lebert its name, 
— rodent ulcer, — which has since been adopted by the best 
authorities. It is most frequently situated upon the eyelids, 
sometimes upon the cheek, or more rarely on other portions of 
the face. I have never known it to occupy the lower lip. As 



EPITHELIAL CAXCER AND EODEXT ULCEK. 49 

the disease is an interesting one, and, in its diagnosis, compara- 
tively a new one, I will venture to quote the following excellent 
description of it from Paget : " It is of irregular shape, but 
generally tends towards oval or circular. The base, however 
deeply and unequally excavated, is usually, in most part, not 
warty or nodular, or even plainly granulated : in contrast with 
cancerous ulcer, one may especially observe this absence, or less 
amount, of up-growth. It is also comparatively dry and glossy, 
yielding, for its extent, very little ichor or other discharge, and 
has commonly a dull reddish-yellow tint. Its border is slightly, 
if at all, elevated ; if elevated, it is not commonly, or much, 
either everted or undermined, but is smoothly rounded or lowly 
tuberculated. The immediately adjacent skin usually appears 
quite healthy. The base and border alike feel tough and hard, 
as if bounded by a layer of indurated tissue about a line in 
thickness. This layer does not much increase in thickness as 
the ulcer extends ; and herein is another chief contrast with can- 
cerous ulceration : in the progress of rodent ulcer, we see more 
destruction ; in the cancerous, we see destruction with coincident, 
and usually more than commensurate, growth. It is only in the 
rarest cases that a groAvth is associated with rodent ulcer." 

Mr. Hutchinson has also published an excellent article upon 
this disease, in the "Medical Times and Gazette" for Sept. 29, 
1860. 

Rodent ulcer requires complete extirpation by the knife or 
caustics. It is very likely to return ; but, in the folio wing- 
cases, did not return, like cancer, in the exact spot : the disease 
seemed to follow on at one side of it : there was no glandular 
complication. (The few cases which follow will serve to illus- 
trate some points in regard to these diseases.) 

Caxcer of THE Lip. — The four foUowino' cases of cancer of 

o 

the lip are principally interesting from being all that have oc- 
curred among females at the ^lassachusetts General Hospital 
for a period of over forty years, and from the fact that three of 
the four were ascertained to have smoked a pipe. They are 
quoted from the Hospital records : — 

7 



50 THE FACE. 

Case XXI. — Cancer of Lower Lip in Female. — " P. G. , 
aged Q2, married; born in Maine. Entered the Hospital, 
May 4, 1852. 

" A healthy-looking old lady ; knows of no hereditary ten- 
dency to malignant disease. Two years ago last summer, she 
suffered from 'canker' in the mouth and inside of lips, upon 
recovering from which, a small ulcer was noticed on the under 
lip, which was soon followed by a small hard ' wart,' not pain- 
ful, but troublesome from constant itching. Last summer, this 
' wart ' became detached, and was followed by an ulcer, which 
has progressed to present appearance. 

"At about the centre of lip projects a red, fungous mass, at 
the base about one inch by three-fourths in diameter ; while the 
everted and protruding fungus measures in either diameter, over 
its convexity, one and one-half inches. The mass is soft, red, 
and the base is not indurated. One or two enlarged lymphatics 
are felt beneath the jaw, tender, but not painful. Tumor, 
though not tender nor painful, gives a sensation of weight, and 
makes speech fatiguing. She has smoked a pipe for years. 
Operated upon, and discharged 'well.' " 

Case XXII. — "E. C, aged 80, widow; born in Ireland. 
Entered the Hospital, Oct. 8, 1853, with epithelial cancer, 
which was removed from the left side of lower lip. 

" Being an out-patient, the liistory of her disease is not known, 
except that she has been in the habit of smoking a pipe for 
many years. She was discharged well." 

Case XXIII. — "B. S., aged 50 ; born in Ireland ; married. 
Entered the Hospital, June 6, 1860. 

" This woman has an ulceration on lower lip, which was first 
noticed about twelve months since. There is some induration 
around the base. Xo enlar element of glands about the neck. 
Otherwise healthy. 

" She has been in the habit of smoking a pipe. 

" She was operated upon, and was in a few days discharged 
weU." 



EPITHELIAL CANCER AND RODENT ULCER. 51 

Case XXIV. — "K. L., widow, aged 70, born in Ireland; 
entered the Hospital, March 9, 1866. 

"Xine months ago, a small ^ scale ' appeared on lower lip, at 
the margin of the mucous membrane, upon removing which a 
slight ^ crack' was noticed. The scale was in a short time re- 
newed, and began to assume the appearance of a scab, which 
has increased in size till now. 

" At present it resembles a wart the size of half of a large 
cherry, circular, firm, edges sharply defined ; surface rough, 
and of a brown color ; surrounding tissue not indurated. It 
is about one-third of an inch in diameter, and is raised one- 
twelfth of an inch from surface ; bleeds easily ; not tender nor 
painful. Xo hereditary tendency of any nature. 

"She has never smoked a pipe nor chewed tobacco. Other- 
wise healthy. 

"Tumor was removed March 10th; and, on the 17th, the 
wound having perfectly united, and all the sutures being re- 
moved, she was discharged well." 

Recorded Cases operated on at the Massachusetts General Hospital. 

Whole number of cases of cancer of lower lip up to Jan. 11, 1861 77 

Males 73 

Females 4 

Addicted to smoking a pipe 44 

Xot in the habit of smoking 7 

Xot ascertained 26 



Case XXV. — Chancre of the TJ]pper Lip, resembling Can- 
cer. — In June, 1864, a servant-girl was admitted into the 
Hospital, with a tumor of the upper and left side of the lip, 
which was supposed to be cancer, and which she entered to have 
removed. She stated, that, during the previous winter, she had 
noticed a fissure on the left side of her upper lip, but did not 
pay much attention to it ; nor did she think it any thing serious, 
until in May it enlarged, and the swelling implicated the adjoin- 
ing parts : suppuration also commenced. Upon entrance there 
was an oblong ulcer, with an everted, fungous surface, about 
two inches by one, having a soft base, discharging moderately, 



52 THE FACE. 

and causing pain ; presenting, indeed, all the appearances char- 
acteristic of cancer. On being questioned upon the subject, 
she thought she might have contracted it while doing chamber 
work at the hotel. Behind her right ear, there was a herpetic 
aiFection of the skin. 

The irritation of the parts was first relieved by a poultice, 
and she was put on a grain of the protiodide of mercury three 
times a day. A week after her entrance, she was etherized, and 
the disease thoroughly cauterized with the acid nitrate of mer- 
cury. It almost at once put on an improved appearance, and 
presented a healthy, granulating surface. On the 4th of July, 
she began to complain of sore throat, irritation about the glands 
of the neck, and her hair began to fall out. The sore gradually 
healed, and the chasm made by the great destruction of parts 
was almost entirely obliterated. She continued for some time 
afterwards under medical treatment as an out-patient. 

Case XXYI. — Extensive Recurrent Epithelial Cancer 
of the Wose, and part of the Face. Operation, Cure. — A 
respectable Irishwoman, 50 years of age, entered the Hospital, 
in May, 1859, for a formidable epithelial cancer, which occu- 
pied nearly the whole nose, and extended on the left side of 
the cheek to about the middle of the left orbit. The nostrils 
were completely obstructed by the tumor, which presented the 
most singular appearance, as of a round cauliflower mass placed 
upon the nose, with the two eyes peering over it. She said that, 
about six or eight years previous, the disease had commenced by 
a long, narrow wart, growing from the left side of the nose. 
This had been removed, by some unprofessional man, with a liga- 
ture. Returning again five or six years afterwards, it was cut 
out by a surgeon. It, however, very shortly re-appeared, and 
soon assumed formidable dimensions. Her health was good, 
and the principal suflering was from the irritating discharge 
supplied by the extensive granulating surface. 

The tumor covering the left nostril was held aside, and the 
ala nasi cut through close to the face. All of the remaining 
portion of the mass was now encircled by an incision, and the 
tumor dissected off rapidly, in the midst of the most profuse 



EPITHELIAL CANCER AND RODENT ULCER. 53 

hemorrhage. The vessels being secured, the large wound was 
narrowed by passing sutures about an inch apart, and tying 
the wound up in segments, so as to obliterate about half of it. 
To the remainder was applied scraped lint, which was allowed 
to dry on. She suffered very little pain after the operation, 
though somewhat feeble, and in a few days was able to leave 
her bed. The wound gradually cicatrized ; and, so long as I 
kept her in view, she remained perfectly healthy, and there was 
no recurrence of the disease. 

EoDENT Ulcer. — Case XXVII. — Rodent Ulcer of the 
JSfose, Eyelids, and Globe. — J. C, 59 years of age, applied 
to me in 1860, for an ulcer, which implicated nearly the whole 
side of the nose, the lower eyelid, and the eyeball of the right 
side. His father was living at the age of 86 years : his mother 
died of consumption. Thirteen years before, while cutting wood, 
a chip flew, and struck him on the cheek under the eye. A ped- 
ler, in the yard at the time, applied a mixture of gun-cotton. 
At night, his face swelled ; and, subsequently, the wound ulcer- 
ated, and spread to* some distance down the cheek. For several 
years it kept its place in the cheek ; but gradually, in spite of 
treatment, it invaded the eyelid, and finally attacked the conjunc- 
tiva, and penetrated to the periosteal membrane behind the eye- 
ball. Dr. James C. White, by applications, had kept it at bay ; 
but finally referred him to me for operation. The appearance of 
the ulceration, which now occupied the side of the nose, and 
had destroyed the left eyelid, and conjunctiva, covering the eye- 
ball, was unlike either the raised disease called epithelial can- 
cer, or lupus, with its cut edges. It had more of the look of a 
dried ulcer, adhering firmly to the deep-seated parts, and with 
but little substance. It answered fully to the description of 
" Rodent Ulcer," described by Mr. Hutchinson in his differen- 
tial diagnosis of the diseases mentioned above. I removed the 
whole disease witli the eyeball, cut away the edge of the upper 
eyelid, with the lashes, dissected up the skin of the cheek, and 
brought the raw edges of the eyelid and cheek together. He 
had a good recovery ; the socket being gradually entirely filled 
up with an adventitious tissue, and the skin being stretched 



54 THE FACE. 

across its external aperture. The nose cicatrized well, and the 
scar afterwards remained healthy. 

On Oct. 10, 1863, a small ulcer, the size of the head of a 
pin, appeared on the edge of the socket. This occasionally 
spread, and was obliterated by grinding into it nitrate of silver. 

This ulceration did not extend much in breadth, but seemed 
to penetrate backwards very slowly : cerebral symptoms oc- 
curred, followed by general deterioration of the health ; and 
he died, about a year afterwards, with very little external mani- 
festation of disease. 

Case XXVIII. — Rodent Ulcer. — H. R. C. was operated 
on by me, Feb. 8, 1866, for the above disease. He was 60 
years of age. About twelve years ago, he had a small pimple 
on the right cheek, near the nose. This remained quiescent for 
some years, when he applied caustic to it, under which it dis- 
appeared. It was followed by an indurated tumor under it. 
About four months since, finding this increasing, and involving 
the skin, he made repeated applications to it of the acid nitrate 
of mercury, which caused a deep ulceration. This increased 
after the applications were stopped ; and, when I performed the 
operation, the base of the ulcer Avas formed by the periosteum 
of the malar bone, and its sides (which felt almost bony) were 
of considerable thickness. Towards the mouth, only the mu- 
cous membrane covered the indurated parts. The orifice on 
the cheek was about the size of a ten-cent piece. The edges 
were rather depressed than elevated, not red, and very friable. 
The whole of this disease was dissected out, and peeled ofi" from 
the bone, leaving it bare, and with a large, deep, gaping 
wound. By some lateral cuts and a little dissection, the skin 
could be slid so as to cover about two-thirds of the wound, 
without tension. The microscopic appearances gave no indica- 
tion of a cancerous afiection. I saw this patient in May : the 
wound on his face was entirely healed, and no marks of disease 
there. An ulceration, however, still existed on the nose, and 
seemed disposed to extend on the inside. A sharp crayon of 
nitrate of silver was freely ground into it so as to destroy the 
tissues as deeply as possible. 



THE EYE. 55 

Case XXIX. — Rodent Ulcer. — J. O. S., 60 years of age, 
applied to me in August, 1863, for an ulceration at the root of 
the ala of the right side of the nose, which was the continuation 
of a disease of ten or fifteen years standing. It had commenced 
with an ulcer on the upper lip, which gradually extended to tlie 
present spot, healing behind, and contracting the lip so that 
the edge was now looped up, and nearly in contact with the 
nose. 

I made various applications to the ulcer, both caustic and 
others, which only served to aggravate it ; and I finally decided 
to operate. 

The loop and hardened cicatrix, together with the ulcer, were 
completely and thoroughly excised. The edges of the lip were 
brought together so as to restore its original breadth. The 
wound healed rapidly, and the patient seemed to be entirely 
cured. 

About a year afterwards, he applied to me again with a small 
ulceration, just within the ala of the nose. After various appli- 
cations, without success, it was cut out, and at once healed. 
Two months afterwards, it re-appeared ; and, extending both 
laterally and in depth, a third operation was performed, more 
extensive than those preceding. This was followed by an 
erysipelatous affection of his face ; and this, subsiding, by albu- 
minuria. He gradually, in the course of some weeks, fell into 
a comatose state, and died. 

This patient was of a very florid complexion, his skin very 
thick, and easily disposed to inflame. Half of every year, he 
lived in a hot climate. The edges of the ulcer presented no 
appearance of tumor, as in cancer of the skin, but were sharp, 
and had a mealy look, easily broken down by the probe. 

THE EYE. 

Case XXX. — Cancerous Tumor of the Right JEye. Re- 
moval. Recovery. — A gentleman, 73 years old, applied to 
me, April 14, 1862, on account of a tumor projecting from 
the right eyeball, between the lids, springing from the sur- 
face of the globe just below the iris. Between two and three 



5Q THE FACE. 

years before, he had what he supposed to be a cataract, which 
destroyed the sight of the eye. Afterwards, he scratched the 
conjunctiva with his nail. This was followed by a small pimple, 
which slowly developed into the tumor. He was finally led to 
ask advice, by the recurrence of frequent and serious bleeding 
from the surface of the tumor, and also by a severe pain over 
the eyebrow, which prevented him from attending to his busi- 
ness, and disturbed his rest at night. On separating the lids, 
the globe was found to be enlarged, and protruded from the 
socket ; the pupil filled with a yellowish-white substance. Very 
large veins ran from the conjunctiva upon the tumor. He said 
he had had an apoplectic attack about three months before, at 
which time he fell upon the floor, striking the tumor, and causing 
a copious hemorrhage. 

Operatioji. — An incision was made at the external angle of 
the eye : the eyeball was seized by double hooks, and removed 
by the scalpel and scissors. The bleeding was free, but was 
checked without plugging the orbit : two or three vessels were 
tied. He gradually and perfectly recovered, and lived a number 
of years afterwards, and died of other disease. 

Case XXXI. — Melanosis of the Right Eye, Removal. 
Recovery. — X. G., 27 years of age, entered the Hospital on 
March 10, 1859, for a tumor of the right eye, which commenced 
six years before as a slight opacity, attended with neuralgic 
pains ; and, about four years after, a tumor appeared just below 
the cornea, seeming to spring from the conjunctiva. Caustics 
were applied, but only aggravated the disease. 

When he entered the Hospital, the globe was enlarged, irregu- 
lar in shape, the anterior chamber was obliterated, and behind 
the pupil a dark-colored substance was seen. Just below the 
cornea, two irregular tumors projected from the ball, between 
the lids, surmounted by a transparent membrane, and con- 
taining dark-colored contents. The whole eye was the seat of 
intense pain ; and an operation for its removal was decided upon 
on this account, from the great irritation produced on the eye- 
lids, and from its probably malignant character. 

An incision an inch long was made at the external angle of 



THE EYE. 57 

the lid ; the globe of the eye was seized by the double hooks ; a 
sharp-pointed bistoury was plunged in at one side, and, the eye- 
ball being circumscribed with the knife, the removal was com- 
pleted by dividing the nerve with strong curved scissors. The 
use of the straight, sharp-pointed knife in the operation is much 
preferable to tlie blunt bistoury usually employed, which is 
manoeuvred with difficulty among the deep-seated tissues, and 
prolongs the operation. In the present case, after the removal 
of the eye, the tissues, which formed the bed of the globe, 
were cleared away with scissors. The operation, as is often the 
case, was followed by very profuse hemorrhage, which was 
easily stopped by forcing one or two sponges into the socket. 
Experience generally shows that an attempt to seize the ves- 
sels with forceps is useless, where the hemorrhage comes from 
such an obscure situation as the loose cellular membrane, deep 
in the socket. 

The compressing bandage was removed on the following day ; 
on the third day, one of the sponges ; and on the fourth, the 
remaining one. The patient left for home in about ten days, in 
a good state of health, and entirely free from pain. 

An examination of the disease by the microscope disclosed 
cancerous matter, with a melanotic coloring. 

The patient presented himself at the Hospital, between one or 
two years after the operation, in a good state of health. 

These two cases show that this formidable disease may be 
removed, with a prospect of prolonging life, and with great 
relief to suffering. 

Case XXXII. — Tumor of the Orbit. Removal. — 
March, 1850. This case was that of a gentleman, 69 years of 
age, who had been healthy previous to the commencement of his 
disease. Four years before, after exposure to a current of cold 
air on his face while sitting at a lecture, he felt a soreness at 
the upper part of the orbit of the left eye. Shortly a swelling 
appeared at this spot, which gradually filled up the socket, for- 
cing the eye from its situation, so as to project it forwards and 
outwards, and prevent vision, except of objects on the sanie 
side. 

8 



58 THE FACE. 

The surface of the tumor was irregular, and covered by en- 
larged veins. It was tense, elasti,c to the touch, and its appear- 
ance at first was that presented by encephaloid disease when 
making its way out from the interior of the cranium. It had 
increased one-third within two months. On a careful explora- 
tion, an indistinct fluctuation was perceptible. There also pro- 
jected from the upper part of the socket a small shelf of bone, 
which entered, and was incorporated with, its parietes. This 
led me to the belief that it might be a case of periostosis, and to 
advise an exploratory operation. 

An incision was made through the skin and orbicular muscle 
of the eyelid. This at once disclosed a bony sac, which, on 
being punctured, discharged about four ounces of fetid pus. 
This sac, as far as possible, was dissected out. On carrying 
the finger upwards, no resistance was encountered for two inches 
above the margin of the orbit. The pressure of the fluid had 
apparently caused an absorption of the lower wall of the frontal 
sinus, and forced upwards that portion upon which the anterior 
lobes of the brain repose. Two openings could be distinguished 
within the cavity; one leading into the right frontal sinus, the 
other communicating, by a very minute opening, with the nasal 
cavities : the interior was lined with a delicate membrane. 

After being once emptied, the cavity was again filled with pus, 
coming, as was supposed, from the other sinus. 

It was estimated that from six to eight ounces of pus escaped 
from the tumor in the course of the day. His physician in- 
formed me, that, for some days after the operation, the discharge 
was " immense ; " but it then gradually decreased. The eye 
nearly regained its natural position, and the sight was as good 
as ever. His health was unimpaired. 

I have once or twice seen cases similar to the above, in which 
the eye has been partially forced from its socket by a bony cyst, 
successfully treated by a free incision, and removal of a portion 
of the parietes of the cyst. 



THE EAE. 59 



THE EAR. 



Case XXXIII. — Epithelial Cancer of the Rim of the 
Right Ear. — A gentleman, 45 years of age, who had always 
led a very temperate life, but had been exposed as commander 
of a ship at sea, applied to me, in May, 1859, with a large 
overhanging epithelial cancer of the upper part of the rim of 
the riglit ear. It had followed pretty nuich the course of cancer 
of the lip, and very much resembled it. It caused no very 
serious inconvenience. For half an inch on each side, the skin 
was scaly, thickened, and dark-colored, as it appears in the 
commencement of this affection. 

AYith scissors I removed the tumor, together with a portion 
of the cartilage of the ear, so as to be sure to include the whole 
disease. I allowed the wound to bleed freely for some time, 
without attempting to arrest it ; for I have often observed, in 
operations about the ear, but more especially in those involving 
the lobe, that a very slight irritation of the wound, such as is 
given by the application of forceps, seems to rouse up the erectile 
tissue, and give rise to troublesome hemorrhage. In removing 
pendulous tumors produced by the irritation of earrings, and 
where sutures have been applied, I have been called to patients 
some hours afterwards, and found the ear in the neighbor- 
hood of the wound greatly swollen, the hemorrhage profuse, 
and issuing from the whole surface of the wound en nappe ; and 
have been obliged to remove the threads, and make soothing 
and cooling applications. In the present instance, it was neces- 
sary to tie a number of arteries, and apply a little prepared 
flax, which has been found very useful in checking slight bleed- 
ings, and as an absorbent for dressing wounds. 

This patient did well. 

Case XXXIY. — Recurrent Fibrous Tumor of the Ear. 
Removal. — June 9, 1865, a young man, 25 years of age, was 
struck by a ball in the left ear, in October, 1860, causing a 
flesh wound, to which adhesive plaster was applied. After two 
weeks, a small, hard tumor appeared at the seat of injury. 



60 THE FACE. 

When this was the size of a pea, it was removed ; and he 
experienced no inconvenience whatever till 1863, when, from 
the scratch of a stick, the tumor re-appeared. It was again 
removed in six months after the injury ; and, in three months, 
re-appeared for the third time. It was about the size of a 
cherry, hard, well defined, embracing the helix of the ear, and 
apparently encondromatous. 

It was removed by a V incision with scissors. Two bleeding 
vessels were tied, and the edges of the wound brought together 
by sutures. A microscopic examination showed it to be fibrous. 



HORNS. 

In the course of my practice, I have had an opportunity of 
observing four or five cases of horny substance^ developed on 
different parts of the body. In 1836 I brought home from 
Paris a wax model of the head of a woman, with a horny excres- 
cence of from eio'ht to nine inches in lens^th OTOwino: from the 
forehead. It was removed, by the celebrated Dr. Souberbielle, 
from the head of an old woman ; and, at my request, the opera- 
tor wrote out a description of the case, he then being over ninety 
years of age. This case — to which I would refer as one of the 
most celebrated cases on record — has already been published 
in the " Transactions of the Boston Society for Medical Improve- 
ment." 

Dr. William R. Lawrence, who obtained this account for me, 
writes underneath it as follows : " Dr. Souberbielle called upon 
me, and left the following description of the woman with the 
horn. It seems that he has never published an account of it. 
Dr. Souberbielle is a curiosity of himself: he is 92 years old, 
and is still an operating surgeon, in full health, and does not 
wear glasses ; was an intimate friend of Eobespierre ; and says 
that he once examined Franklin for stone in the bladder. He 
says that he has performed the high operation for stone between 
fourteen and fifteen hundred times ; and that that is the only one 
which ought to be performed, except in children." 

M. Rayer, in his work on diseases of the skin, mentions the 
case of a woman under the care of Dubois, at the Hospice de 



HORNS. 61 

Perfectionnement, who had a horn occupying the forehead six 
inches in diameter and six inches in height. It was very hard 
at its summit, and was embraced at its base by a ring of epi- 
dermis, such as is seen at the root of the nails. This tumor 
gradually increased, so as finally to push down the skin of the 
forehead and cover the eyelids : a fetid odor arose from it. 

I have seen one or two cases of tumors resembling these 
horny productions ; one, on the face of an old lady, between 
two and three inches in height, with a base of an inch and a 
half or two inches in diameter, of a dark brown color, and of 
some years' duration. Upon using slight force, it came off in 
my hand, leaving at its base an ulcerated surface. The excres- 
cence was evidently composed of dried layers of pus, originating 
in a chronic ulcer. 

The following case of a true horn of small size I operated 
on in 1863 : — 

Case XXXY. — Horn on the Face. — An Irishman, 60 
years old, with rather a dried, shrivelled skin, presented himself 
at the Hospital, June 6, 1863, having a horny excrescence 
growing from the skin of the face, on the right side, and on a 
level with the edge of the lower jaw. The horn itself was rather 
more than an inch long, situated on an elevated base or tumor 
about half the size of a small English walnut. The whole 
growth was removed by two incisions, leaving the healthy cellu- 
lar membrane below. A perpendicular section of this tumor 
displayed, — first, at the base, fat, forming the mass of this part 
of the tumor ; second, this was surmounted by three-fourths of 
an inch of compact epidermic tissue, on top of which was the 
horny structure, disposed in cup-like layers. 

I have also lately removed from the forehead of a female, just 
between the eyebrows, a horny tumor of about three-quarters of 
an inch in length, and of between one and two years' growth. 
It had at first the appearance of a wart, this being gradually 
surmounted with a horny production. It was removed as in the 
former case ; and healed, hardly leaving a scar. 



62 THE FACE. 



DEVIATION OF THE SEPTUM OF THE NOSE. 

We seldom observe in books on surgery any reference to the 
question of the treatment of this affection ; it being principally 
noticed in connection with the differential diagnosis of polypus, 
and mucous thickening of the nasal cavities. It is, however, an 
affection of some importance, and one in consequence of which 
patients often apply for treatment. It would be supposed, that 
what is lost in freedom of respiration by the obstruction on one 
side would be made up on the other ; but this is not the case. 
The obstructed side becomes congested, and this congestion seems 
to be transmitted in part throughout the whole extent of the 
nasal cavities, causing difficulty in breathing, inordinate secre- 
tion from the nostrils, more or less congestion about the head, 
and a general disturbance of the health. Patients with this dis- 
ease often apply for advice, supposing it to be polypus ; and 
sometimes, from the great bulging-down of the spongy and 
thickened mucous membrane of the septum on one side, it would 
seem easy for the mistake to be made. But, on examining the 
tumor, it will be found, first, always to belong to the inner 
instead of the outer side of the nasal passage ; secondly, on 
pressing on it with a probe, or with the little finger, it will be 
found unyielding ; and, thirdly, by passing a probe into the 
other nostril, it will fall into the cavity made by the deviation, 
corresponding to the prominence on the other side. 

The method which I have adopted for the treatment of these 
cases will be best illustrated by one or two examples, which may 
serve to represent quite a number of others which have fallen 
under my observation. 

Case XXXVI. — Deviation of the Sejptumii of the Nose, — 
A child, 12 years of age, of a scrofulous habit, was brought to 
me by its parents, having an extreme deviation of the septum to 
the right side, completely obstructing the passage, and giving 
rise to the train of symptoms already mentioned as belonging 
to the severe forms of the affection. I commenced, with much 
difficulty and great resistance on the part of the patient, by 



DEVIATION OF SEPTUM OF NOSE. 63 

passing a small bougie into the obstructed nostril, keeping it 
upon the floor of the cavity, so as to prevent its penetrating 
either in an upward or lateral direction. After this had been 
done for several days in succession, a narrow passage was 
opened. Into this was passed a piece of prepared sponge, well 
oiled, about an inch long, of a cylindrical shape, and pointed at 
its extremity. This was secured on the outside with a string, 
which was fastened around the ear. The expansion of the 
sponge at first caused great irritation, which would have gone 
on to ulceration, had it not been removed after twenty-four 
hours. After the irritation had subsided, the sponge was again 
introduced; and, by proceeding with caution, and removing it 
from time to time, an opening was made large enough to allow 
as free a passage of air as upon the other side. 

Case XXXYII. — Deviation of the Septum of the Nose. — 
A young gentleman, 18 years of age, with marks of a strumous 
diathesis, consulted me on account of a deviation of the septum to 
the right side. He could breathe freely through the left nostril ; 
but on the right side, he could, with great effort, force throuo-h 
only a small portion of air. The tumor formed by the septum 
looked much like a polypus, forced down to the external openino* 
of the nostril. I first passed a bougie along the lower side of 
the tumor ; then the little finger, well oiled, was very slowly, 
and with much difficulty, insinuated into the passage, forcino- 
the septum over, and guided at the same time by a finger in the 
other nostril. On withdrawing the finger, he breathed freely 
through the right side. He was now advised to introduce twice 
a day a bougie ; and at night to wear a little instrument con- 
structed with a spring, so that it could be closed by pressing the 
blades together, and then allowed to expand after introducing it 
into the nostril. After this course had been pursued for a short 
time, the passage seemed to be fully dilated; but, on its beino- 
neglected for several months, the difficulty recurred in part, so 
as to require a repetition of the treatment. 

Case XXXVHI. — Deviation of the Septum N'asi, icith 
apparent Calcareous Deposit on the external end of the 



64 THE FACE. 

Cartilage, — A boy, aged 12, was brought to me, June 24, 
1866, by his physician, for what appeared to be a tumor in the 
riirht nostril, and which bulo'ed out the side of the nose. It 
had come on gradually, finally completely obstructing the breath- 
incf throuo^h that nostril. 

I found it to be the affection mentioned above. The surfxce 
of the tumor had on it one or two streaks which looked like 
ulceration, but which, on being examined with the finger, 
proved to be calcareous deposit on the end of the cartilage, 
where it pressed on the mucous membrane. At first, there 
seemed to be no visible opening into the nostril ; and it was with 
some difficulty and with great resistance from the patient, that 
the probe could be insinuated along the floor of the nostril. 
This was replaced by a conical gum-elastic catheter, through 
which he breathed freely. I advised the treatment pursued in 
the former cases. 



TUMORS OF THE JAW-BOXE. 

In the substance of the superior and inferior maxillas are found 
tumors of various character, myeloid, cystic, cancerous, fibrous, 
cartilaginous, and osseous ; more superficially, and springing 
from the bone, may occur epulis. 

Operations for the removal of large tumors of the jaws were 
formerly very rare, and were considered highly dangerous. By 
the use of improved cutting forceps of large size, the upper jaw- 
bone may now be removed with but little trouble or danger ; 
being, in fact, a less formidable operation than the excision of 
the lower jaw. The deformity, too, is much less than might be 
expected ; as the cavity is, in a measure, filled by adventitious 
tissue, and may also be partly closed by artificial contrivances. 

Myeloid Tumors of the Jaw. — Myeloid tumors in the 
jaw are rare, and, at a late stage of their existence, are often 
distinguished with difficulty from that external affection called 
"epulis." The following cases characterize well the history and 
appearance of this disease. 



IklYELOID TU^IOES OF THE JAW. G5 

Case XXXIX. — Myeloid Tumor of the Loicer Jaw. — A 
ladj, 21 years of age, applied to me in 1861, with a hard tumor 
on the right side of the lower jaw, in front of the socket of tlie 
second molar tooth, which had been extracted a couple of years 
before. Since its extraction, she had had neuralgic pains in that 
side of the face. The tumor had somewhat the feeling of a 
cystic growth. There was no disease of the gum. I cut down 
upon it, and removed it even off with the jaw Avith the bone 
forceps. The wound rapidly healed ; and I did not see her for a 
year, when a slight bulging-out of the jaw was perceptible at 
that spot, but not sufficient to demand surgical interference. 
In Xovember, 1865, she consulted me for a fungoid growth 
resembling epulis, occupying most of the horizontal portion of 
the jaw on the right side, which had appeared within the last 
three months. The lower edge of the bone still preserved a 
clean margin. It was decided to expose the disease by a free 
external incision, and to be o'overned bv circumstances as to 
removing the whole substance of the jaw, or leaving the lower 
rim of bone. This was done in the manner related in the next 
case, and the tumor exposed to view : the facial artery was tied 
before being cut, to avoid the great and troublesome flow of 
blood which usually takes place when that vessel is divided. 
A tooth was now removed in front of the disease, and the 
wisdom-tooth behind ; and, it being found possible to preserve 
the edge of the jaw, perpendicular incisions were made with a 
small handsaw, a. horizontal gTOOve underneath the tumor with 
Hey's saw, and the division was completed with powerful bone 
forceps. On removing the tumor, a small cup-like depression 
remained in the centre of the place from which it was taken ; 
and, although this appeared c[uite healthy, as a matter of pre- 
caution it was scooped out with a chisel. 

On making a section of the tumor, the bone was found ex- 
panded to a shell, and contained a soft material similar to that 
to which the name of myeloid has been given, of a soft uniform 
appearance, and which, on examination with the microscope, 
proved to be a fine specimen of that disease. It had broken out 
from its osseous envelope on the outside, and then had spread 
rapidly over the gums in the vicinity. 

9 



66 THE FACE. 

The wound was brought together by quite a number of 
sutures, and united nearly throughout by first intention. The 
patient had scarcely any constitutional disturbance. 

Case XL. — Myeloid Disease of Lower Jaw. — A young 
married woman, 19 years old, whose general health had been 
very good, consulted me, in June, 1865, for a tumor of the 
lower jaw. It had commenced, two years before, with pain in 
the first molar tooth of the right lower jaw, which was thought 
at the time to be due to an " ulceration of the tooth." A swell- 
ing, which made its appearance a year and a half after, gradu- 
ally increased. The tooth was then extracted : in the course 
of six weeks the tumor doubled in size. It was easily felt 
externally, extending from an inch from the angle of the jaw 
to the canine tooth. On the inside of the mouth it bulged 
out, and protruded upwards through the cavity formerly occupied 
by the tooth. She had little or no pain, and experienced no 
inconvenience from it. Her general health was very good. 

OiDeratioyi. — An incision was made from the zigoma, sweep- 
ing around under the ramus of the jaw, and terminated near the 
lip in front of the angle of the mouth. The facial artery, which 
was now exposed, was seized, with two pairs of forceps, above 
and below, divided between them, and the two ends tied. The 
mucous membrane was now cut through into the mouth, and 
the tumor exposed. The teeth in front and behind being ex- 
tracted, the jaw was sawed through with a small saw, and was 
then dissected out. 

On examining the tumor, the walls of the jaw were found 
expanded by the growth from within, and deficient at the upper 
portion, where it protruded. On making a longitudinal section, 
the gross appearances were found to be characteristic of myeloid 
disease ; being compact, uniform in appearance, with a few of the 
characteristic " blotches." 

Under the microscope, there were found elongated and many 
nucleated cells. 

The wound healed rapidly ; but her health remained delicate 
for some months afterwards. 



MYELOID TU3IOI18 OF THE JAAV. 67 

Case XLI. — Removal of Up'peT Maxillary Bone for 
Myeloid Disease. Palliative Operation tico years before. 
Artificial Substitute. — A young man, 19 years of age, en- 
tered the Hospital, April 7, 1864. He was formerly a soldier. 
A year and a half before, a small swelling was noticed upon the 
outside of the gum of the upper jaw, near the first molar tooth, 
following too early exposure after an attack of typhoid fever. 
Thinking a carious tooth was the cause of the swelling, it was 
removed ; but this had no effect on the tumor. Nine months 
after, it began to increase in size : on admission to the Hospi- 
tal, it measured one and a half inches in diameter ; was ovoid, 
hard, not tender upon pressure ; painful at times, pain " stream- 
ing up " the side of the face, and at such times the eye was 
frequently bloodshot. 

April 9th, he was etherized ; the lip was drawn up, exposing 
the tumor. An incision was then made in the protruding wall. 
Through this opening, the finger was passed into a cavity con- 
taining a pulpy substance, which partly filled the antrum, and 
which was scooped out. 

A fragment was examined under the microscope, and found 
to contain the many nucleated plates of myeloid growth, and 
distinct, isolated nucleated cells, such as are usually found in the 
same connection. 

Sixteen days after, he was discharged, relieved. 

Nov. 29, 1865, he returned again for the removal of the 
upper maxillary ; the disease having recurred, and made consid- 
erable progress. The right side of the cheek was occupied by 
a hard tumor, expanding the anterior wall of the antrum, and 
impinging on the malar bone. The aperture previously men- 
tioned was filled with a dark-colored, fungoid mass, of the size 
of a chestnut. It was decided to remove the whole bone, as 
affording the only hope of cure. It was done in the following 
manner, which I shall describe in detail, as being the method 
which I have ordinarily pursued for the removal of the upper 
maxillary bone, and which leaves as little deformity as any of 
the methods proposed, where the disease is extensive. Being 
etherized sufficiently to carry him through the preliminary in- 
cisions, a pointed bistoury was plunged through the skin just 



Q8 THE FACE. 

above the zygomatic process of the malar bone. A curved 
incision was then made throuo-h the skin and muscles to the 
angle of the mouth. A bit of sponge had been previously stuffed 
into that cheek to prevent the blood from flowing into the fauces. 
When the skin of the face is more flaccid, as in old persons, 
this incision may be commenced lower down, thereby dividing 
fewer filaments of the facial nerve, leaving less paralysis. A 
too limited incision, however, embarrasses the section of the 
bones. The flap was dissected rapidly up, the right ala of 
the nose cut away, and the contents of the socket dissected par- 
tially from the floor of the orbit. The bones being well cleared, 
the vessels in the flaps were tied, the blood was cleared away 
from the wound, and ether was ao^ain o-iven. With a small hand- 
saw, a groove was made in the frontal process of the malar bone 
and through the zygomatic process, and the section completed 
by the cutting forceps, the former incision extending into the 
spheno-maxillary fissure. The nasal process of the superior 
maxillary bone was now cut through in the direction of the same 
fissure. The mouth being held wide open, a vertical incision 
was made with a strong pointed knife, through the coverings of 
the hard palate as far back as the palate bone, and a lateral one 
from the termination of this behind to the root of the last molar 
tooth. Liston's large cutting forceps were now used to divide 
the bone, which they cleanly and efficiently did ; the first incisor 
tooth having been previously removed. The whole mass was 
now seized with powerful hooked forceps, and an attempt made 
to depress it ; but it held fast at its junction with the pterygoid 
process of the sphenoid. A chisel was therefore driven in be- 
hind the bone, and an attempt made to break its attachments, 
but without success. A blunt chisel was then inserted between 
the two maxillary bones ; and, by a prying motion, the adhesion 
to the bone behind was broken. The remaining soft attach- 
ments were divided by blunt curved scissors. The maxillary 
artery, which bled freely j was tied. When all hemorrhage had 
ceased, the edges of the skin were accurately brought together 
by sutures, care being taken to nicely adjust the lip ; and one or 
two sutures were inserted inside the mouth. 

The patient was greatly depressed, and stimulants were freely 



MYELOID TIBIORS OF THE JAW. 69 

administered. There was an oozins: from the wound dm^ins; the 
same day. For some days the pulse remained feeble and the 
strength much depressed. In two weeks the powers of life re- 
vived, and he then recovered with great rapidity. The paralysis 
was less than usual, and with a slight effort the eyelids could 
be nearly closed. Sight Avas not impaired. The union of the 
wound was perfect, except at one small spot, where a salivary 
fistula seemed to threaten. 

On inspection of the diseased part, the cavity of the antrum 
was found filled with a soft, dark-colored, spongy mass, which, 
under the microscope, p;resented the well-marked characters of 
myeloid growth. The disease was entirely removed by the 
operation. 

HemarJcs. — The incisions in the soft parts in this case leave 
as little deformity as any of those suggested for the excision of 
this bone. Gensoul recommends incision of the upper lip, a 
cross cut through the cheek, and a perpendicular one at the end 
of this, leaving three very disagreeable scars. Fergusson, a 
simple cut through the upper lip into the nostril, or, possibly, 
a continuation of this incision around the margin of the ala, up 
the side of the nose, and along the edge of the orbit, if neces- 
sary. In regard to the bones, it has been advised to make one 
cut through the maxillary process of the malar bone into the 
spheno-maxillary fissure, instead of dividing the zygoma and 
the frontal process of the malar bone. The objection is, that the 
tumor generally occupies the whole cheek, and prevents the exe- 
cution of the plan proposed. The trying point is the adhesion 
of the maxillary bone to the pterygoid, made more firm by 
inflammatory action, so that in malignant diseases, in attempt- 
ing depression of the bone, the front part of the antrum is apt 
to break away from the posterior portion, requiring the back 
part to be subsequently removed. 

The slight deformity left from so extensive an operation is 
remarkable. There is a slight paralysis in the cheek, and at 
first a confusion in the speech and some difficulty in deglutition, 
which can be almost completely remedied by artificial appliances 
of gold, gutta percha, or hard India-rubber. 

With a little management, a nuich larger portion of the soft 



70 THE FACE. 

parts covering the palate might be saved, as they peel oiF easily 
when the bone is depressed. 

This patient recovered perfectly. The salivary fistula, which, 
it was feared, would be permanent, closed after two or three 
applications of caustic. The voice and deglutition were, of 
course, very much impaired by the great cavity left after the 
removal of the bone. These, however, were completely restored 
by the ingenious construction of a hard rubber obturator and 
palate, made by Dr. Eufus E. Dickson, dentist. He now 
speaks well, and liquids no longer regurgitate through the 
nostrils. 

Epulis. — It is necessary to distinguish epulis from myeloid 
disease of the jaw. The latter is usually a disease of the inte- 
rior of the bone, which, extending outwards, after a while pre- 
sents an appearance similar to the former. Myeloid disease, 
involving the substance of the bone, and changing entirely the 
structure of the part, as is well described by Paget, requires 
the excision of that portion of the jaw which is attached. 

Epulis is comparatively superficial. It arises from the peri- 
osteum and grows outward ; is more common in young persons, 
though it frequently occurs in advanced life. If the gum is 
removed with the sockets of the teeth from which it springs, the 
disease is cured ; but care should be taken to cut deeply enough 
into the bone to remove the whole, as otherwise it will be likely 
to return. 

In the case to be adduced, the disease had become so deeply 
seated, and attacked to such an extent the neighboring parts, 
that removal of the whole bone, which was very small and deli- 
cate, was finally required. 

Case XLII. — Removal, throiigli a Small Opening, of 
Hal f of the Lower Jaw-hone, Epulis. — A married lady, 30 
years of age, consulted me, in June, 1860, for a fungous ex- 
crescence occupying the alveolar j)rocesses, and sockets of the 
three last molar teeth. The disease ran up a little on the ramus 
of the jaw, and lapped over on each side. A year previous, she 
had submitted to the removal of a molar tooth, and the jaw had 



EPULIS. 71 

not since been in a sound state. A short time afterwards, a 
fungous growth from the diseased socket was removed. It 
gave her very little pain, but was increasing, had taken in the 
mucous membrane on the outside of the jaw-bone, and was 
creeping up on the ascending part of it. She was desirous to 
have an operation done at once, so that she might return home 
that day. This I did, as thoroughly as possible, in the ordinary 
way, with the cutting forceps, going deep into the jaw, and 
removino' the disease so far as it could be detected. The bleed- 
ing for the moment was profuse, obscuring the after steps of 
the operation, as it always does when an attempt is made to cut 
away pieces of the jaw, without making an opening through the 
cheek ; and on this account the subsequent safety of the patient 
is often sacrificed to the natural desire of avoiding a deformity. 
The hemorrhage w\as checked by the local use of perchloride of 
iron. In a fortnight I saw her again, every thing apparently 
having done well. 

On a very careful examination at this time, I detected, deep 
in the jaw, remains of the diseased tissue, and, knowing that any 
delay would be fatal, proposed to the patient an operation for 
the exposure of the bone by an external incision ; and, if it was 
then found necessary, the removal of the whole bone. Being a 
person of great courage and decision, she at once consented 
without hesitation to submit to any operation that was thought 
necessary. 

On the 20th of June the jaw was exposed. What was left 
of it was found to be very narrow, and invaded by disease, which 
ran up on the ascending ramus. It was at once decided to disar- 
ticulate the bone, which was done in the usual manner. 

The wound united by the first intention. The constitutional 
irritation was slight. On the fourth day she sat up, and on the 
sixth was out of doors ; on the eighth she returned home, a dis- 
tance of eighty miles. A daguerrotype likeness taken at this 
time scarcely shows the marks of the operation. 

November, 1863, being in town, she called on me. She was 
in full health, and was free from disease. She talked plainly ; 
and used the remaining portion of the jaw well in mastication. 
The gap caused by the removal of bone was filled up with 



72 THE FACE. 

dense fibrous tissues, which seemed to answer all the purpose of 
bone for steadying it. The incisor teeth above and below were 
in apposition. There was no paralysis ; and the marks of the 
operation were scarcely visible. 

Cystic Tumors of the Jaw. — The appearance of these 
tumors is generally very formidable ; and the practice, for 
the most part, when the whole substance of the bone is 
dilated into a mere sac, almost entirely deprived of osseous sub- 
stance, has been, until very recently, to remove the portion of 
the jaw involved by the tumor. When the tumor has grown 
simply at the expense of the outer table of the bone, either of 
the upper or lower jaw, without involving its whole substance, 
it has been customary to explore the cyst and remove a portion 
of it, causing inflammation and obliteration of the cavity, as in 
the case of cysts occurring in soft parts. Dupuytren, in his 
collected articles on Diseases of the Bones, has attached more 
importance to this question than any other writer ; and illus- 
trates, by cases, the effect of exposing the tumor by external 
dissection, removing a portion of the sac, and by applications 
effecting its obliteration. Professor March, of Albany, has 
written a valuable paper on this subject in the " Transactions 
of the Medical Society of the State of New York." Professor 
Gross and others have suggested the idea, that, in the large 
cysts which involve the whole bone, and which formerly were 
known under the name of " spina ventosa," the treatment should 
be the same. In one of the cases cited by the former gentle- 
man, the extirpation of the bone was finally found necessary 
after this plan had been tried. 

As to the causes of these diseases, they are various. In the 
jaw, they probably arise, in most instances, from irritation at 
the roots of the teeth ; in the long bones, the head of the tibia 
for instance, from blows. 

In 1862, I published, in the "Boston Medical and Surgical 
Journal," a case occurring in an elderly woman, of a cyst which 
involved the ascending portion and condyles of the jaw, and 
which I removed ; not thinking it safe, in a person of her age, 
when the disorganization of the jaw seemed to be so complete, 



CYSTIC TUMORS OF THE JAW. 73 

to run the risk of an experimental mode of treatment. Since 
that time, I have had an opportunity of trying the conservative 
plan of treatment in t^YO instances, which I propose shortly to 
relate. 

Notwithstanding the principle wliich has been suggested or 
hinted at for the treatment of large cystic tumors of the jaw, 
none of the writers on the subject have presented cases, — where 
complete destruction of the bone has taken place, leaving nothing 
but a delicate cyst, — as having been successfully treated by the 
method adverted to. Dupuytren, in his work on Diseases of 
the Bones, gives several cases treated without excision ; some 
of them, however, unsuccessfully. jNI. Kclaton has also written 
on the subject, referring for cases to the work of Dupuytren, and 
advising the puncture of the cyst, and the stuffing of its cavity 
with lint. Mr. Erichsen says, that, " when the cysts are so large 
that they have destroyed the integrity of the bone, or when 
they are associated with a large quantity of fibrous tissue, so as 
to constitute true fibro-cystic tumors, excision of the diseased 
bone must be practised." JMr. Stanley, in his " Treatise on the 
Diseases of tlie Bones," describes perfectly the affection, but 
does not allude to any other operation than the " removal of the 
tumor, and of the portion of the bone from which it has 
arisen." 

In the following cases, the treatment consisted in the punc- 
ture of the sac within the mouth ; evacuating its contents, 
and, at the same time, obliterating the cavity by crushing in its 
walls ; and, lastly, in keeping up, by injections, &c. , a sufficient 
degree of irritation to favor the deposition of new bone. The 
comparative mildness of this mode of treatment, and the excel- 
lent character of the results, combine to award the preference 
for this operation over excision, or even the large external 
incision adopted by Dupuytren. 

Case XLIII. — Cystic Tumor of the Lower Jcau. — A 
young woman, aged 25, with light hair, blue eyes, and delicate 
skin, applied to me in the spring of 18G2, on account of a large 
tumor involving the whole right side of the jaw above its angle. 
The tumor was of a globular shape, extended back under the lobe 

10 



74 THE FACE. 

of the ear, forwards so as to encroach upon the cavity of the 
mouth, and upwards so as to press upon, and somewhat to over- 
lap, the zygoma. The external surface of the tumor was 
smooth and shining, slightly oedematous ; and she suffered from 
its pressure upon the surrounding organs. It had commenced, 
some years before, by a swelling at the root of the wisdom- 
tooth of the right side ; and the inconvenience caused by its 
pressure had become so great as to lead her to take measures 
for its removal. 

Upon consultation, it was decided that a portion of the jaw 
would probably require removal ; the tumor having been first 
exposed by an incision made inside of the mouth, to verify its 
character. 

The following operation was performed under the influence 
of ether. An incision was made in the most prominent part of 
the tumor in the mouth, upon which a large quantity of glairy 
fluid escaped. Upon passing the finger into the opening, it was 
found that the whole jaw at this point, with the articulating and 
coronoid processes, was expanded into a mere shell, at some 
parts as thin as parchment, and destitute of osseous substance. 
It was without solid contents. Under these circumstances, and 
considering the good health and youth of the patient, it was 
determined to make the attempt to save the jaw. A portion 
was therefore removed from the sac; and, with the fingers, the 
sides of the cavity were made to collapse, so as to come in con- 
tact with each other. In order to excite still farther irritation, 
a bit of cotton cloth was forced into the interior, and the end 
left projecting into the mouth. A moderate degree of irritation 
followed; and, at the end of a day or two, the pledget was re- 
moved, suppuration having commenced in the sac. The aper- 
ture was dilated, from time to time, by the introduction either 
of the finger or of a bougie, and the sac injected with tincture 
of iodine. At the end of two or three weeks, she left the 
Hospital, with the tumor reduced to about one-half its original 
size. From that time until the present, she has occasionally 
visited me at my house ; and, by keeping the external opening 
free, and occasionally irritating the interior of the sac, a solid 
mass of bone has been deposited anew, and the jaw has resumed 



CYSTIC TUMORS OF THE JAW. 75 

somewhat of its original shape. The sac is in the way of becom- 
ing entirely obliterated. 

In November, 1863, I again saw the patient, who came to 
consult me, not about herself, but about a friend. All signs 
of the tumor had disappeared, and the jaw had regained almost 
its natural shape ; but a small aperture still existed at the site 
of the former opening into the mouth, and a glairy fluid was 
occasionally discharged from it. She was quite well, and all the 
functions of the jaw were perfectly performed. 

Subsequently, she applied to me with a tumor of a smaller 
size, which had appeared in the jaw anterior to the site of the 
first one. It was treated in a similar manner, with a similar 
result. 

Case XLIY. — Cystic Tumor of the Loiver Jaw, — May 
23, 1863, Dr. Bennett of Uxbridge, Mass., brought me, as a 
patient, a gentleman 56 years of age, with a large tumor on the 
right side of the face, occupjdng the parotid region. He was 
pale and sallow, much emaciated ; and his aspect at first struck 
me as that of a person suffering from malignant disease. He 
said that, five years before, while eating, he had the sensation 
of something giving way in the neighborhood of the ascending 
ramus of the lower jaw. Shortly after, a tumor appeared in that 
region, which had slowly increased to its present size. Before 
making an examination, it was not easy to say whether the tu- 
mor was connected with the parotid gland or with the jaw. 
From the commencement of the disease to the present time, mas- 
tication, and, for a good part of the time, deglutition, had been 
much interfered with. The tumor had been examined by many 
physicians of experience, and by most of them considered as a 
parotid tumor, and as the patient inferred, although he was not 
directly told so, of a mahgnant character. It extended back- 
wards into the parotid region, upwards upon the face, and 
inwards so as to occupy the right half of the palate ; and was 
covered with a highly irritable mucous membrane, somewhat 
osdematous, and similar to what we often see investing malig- 
nant tumors in the mouth, which have made their way through 
from the neck. Dming an examination, the patient said there 



76 THE FACE. 

had been of late a slight discharge of fluid into the mouth ; 
and, on making a careful inspection, a minute aperture was 
detected at the point where the last molar tooth had been 
removed. 

On introducing a probe at this point, a jet of serum, mixed 
with flakes of lymph, was projected to a considerable dis- 
tance. I immediately Enlarged the opening with the knife, 
so that I could introduce the finger. This was a matter of 
some diflSculty, however, as the patient's jaws had been for 
a long time nearly closed in consequence of the disease. The 
finger penetrated into a large sac, extending far out of reach ; 
and, on investigation, it soon became evident that the whole 
tumor was formed by the expansion of the jaw, from the de- 
velopment within it of an immense cyst. On withdrawing the 
finger, a barrier of bone was felt, extending across the jaw ; 
and behind it, under the first molar tooth, another smaller sac 
was discovered. 

I now decided to treat this case in a similar manner to 
the preceding one. An oblong piece of about an inch in 
length and half an inch in width was removed, by scissors, from 
the wall of the cyst ; and with a finger of one hand in the 
mouth, and a finger of the other on the outside of the face, 
the sides of the cyst Avere broken down, giving way under the 
pressure like parchment, with a crepitating noise. The pro- 
jection of the tumor on the face, as well as within the mouth, 
became in a great measure effaced. There was a slight but un- 
important effusion of blood. The patient returned home, under 
the charge of his physician, with the intention of pursuing 
pretty much the same course as was adopted in the former in- 
stance. On account of his age, and the debility caused by the 
want of proper nourishment, owing to the difficulty of mastica- 
tion, he was ordered tonics and a nutritious diet. 

About four weeks later, I saw him again. Every thing had 
ofone on well : the tumor was not more than a fourth as laro^e 
as formerly, and ossification had commenced in the walls of the 
sac. His health was wonderfully improved, and his complexion 
had assumed a healthy hue. 

Dec. 8, 1863, I saw him for the third time, so altered for 



CYSTIC TUMORS OF THE JAW. 77 

the better as scarcely to be recognized as the same person. 
The jaw externally had resumed its natural shape ; and, on ex- 
amination with the finger, its distinctive anatomical marks and 
processes could be felt. On the inside of the jaw, where 
the incision had been made, a deep sulcus was observed, lined 
with mucous membrane, into which a probe could be passed 
into the ascendinof ramus. There was no discharo-e to be de- 
tected, and the power of mastication was as good as ever. The 
only trouble he experienced was from the lodgment of food in 
this cavity. 

Three months later, he was seen with the jaw in a perfectly 
healthy condition, performing all its functions ; and the only 
change from the normal state was, perhaps, a more solid and 
somewhat thickened condition than natural, with the sulcus 
existing at the back part, where the tumor had originated. 

In 1866, he made me a visit, as he said, to show the com- 
plete success of the operation. 

Case XLV. — Cystic Tumor of the Upper Jaw. — A young 
lady, 16 years of age, of English parentage, was brought to me, 
in May, 1865, on account of a tumor which had been develop- 
ing for the last three years in the alveolus of the right upper 
jaw, just above the canine and bicuspid teeth. Three years 
before, the nerve of the canine tooth had been destroyed by 
arsenic, and the carious cavity filled with gold ; the first bicus- 
pid being also filled at the same time. Irritation soon com- 
menced at the roots of these teeth ; and gradually, and almost 
imperceptibly, a swelling appeared there. A month before she 
came to me, this tumor opened at its most dependent part, 
discharging a glairy fluid, which continued to exude until I saw 
the case. 

The aperture admitted a small probe, Avhich penetrated into 
a deep, smooth cavity. With the finger, the tumor from below 
appeared firm ; but, when pressed upon under the gum, a de- 
gree of elasticity was distinguished. 

Unformed the parents of the young lady, that the disease was 
a cystic tumor of the bone, and advised an operation. This 
was assented to. The patient was etherized, and a cut made 



78 THE FACE. 

into the tumor. The mucous membrane was then dissected 
up from its surface, so as to expose so much of the bony 
sac as would admit of a free opening being made into it ; and 
a portion of the bone was removed with scissors. The finger 
could now be passed freely into the cavity, which was quite 
smooth, and entirely lined with membrane : it was not penetrated 
by the roots of any of the adjacent teeth. The cavity was 
stuffed with lint, in order to excite inflammatory action, for 
the purpose of obliterating the sac. 

The operation had all the eifect that could have been desired. 
In the course of a couple of months, granulations filled up the 
the cavity, entirely obliterating it. 

She was completely relieved of the disease. 

One or two other cases of cysts in the upper jaw, I have 
treated in the same way, with a similar result. 

Case XLYI. — Removal of the Lower Jaio for a Cystic 
Tumor. Sithsequent Ligature of the Carotid A.rtery. — 
Mrs. W., a widow, 49 years old, had had the wisdom tooth of 
the right side of the lower jaw extracted about twelve years 
before I saw her : the socket remained quite sore for some time 
after the removal of the tooth. Six years after, the angle of 
the jaw began to enlarge ; and the bone gradually expanded 
so as to form a tumor the size of a hen's Qgg, which encroached 
upon the cavity of the mouth, and displaced the tongue and 
other organs. The tumor was slightly elastic to the touch, and 
had become a little tender on pressure ; with this exception, 
there was no pain, and no inconvenience in mastication. The 
disease involved the angle and ascending ramus of the jaw, and 
extended forwards as far as the second bicuspid tooth. 

March 30, 1861, the portion of the lower jaw behind the 
second bicuspid was removed in the usual manner, though when 
the bone was seized with strong forceps, in order to raise it from 
its adhesions to the surrounding parts, on the application of a 
very slight degree of force it gave way, and disclosed the fact, 
that the whole angle, the ascending ramus, and the processes of 
the jaw, had become reduced to a sac or cyst containing a thick 
yellow fluid. The operation was finished, for the most part, by 



CYSTIC TL^IORS OF THE JAW. 79 

the fingers ; and the lingual nerve, which lay close upon the inner 
surface of the tumor, was dissected out and saved. Several ves- 
sels were tied ; and the edges of the wound were brought to- 
gether by sutures, three of which were placed inside the mouth. 
No severe constitutional disturbance followed the operation ; 
and on the third day the wound was nearly united. Two days 
later, the fiice swelled, and the wound began to discharge pus. 
In the course of another fortnight, the wound had healed, with 
the exception of a small opening at its lower angle. On the 
17th of April, a slight hemorrhage, of perhaps two ounces, 
took place from this opening ; and on the night of the 27th, 
when the patient had so far recovered from the operation as to 
think of going home, profuse bleeding occurred, which was 
with difficulty controlled by a sponge and compresses. On the 
29th, it became evident that the hemorrhage could not be con- 
trolled, by even the most careful plugging of the wound ; and 
the ligature of the carotid artery seemed to offer the only 
chance of saving life. The patient was therefore etherized, and 
the sponges removed from the wound. The finger passed 
readily from the external aperture, corresponding in position to 
the angle of the excised jaw, as far as the glenoid cavity of the 
temporal bone, which felt rough and carious. Pressure upon 
the carotid artery of the affected side diminished the bleeding, 
but did not entkely check it ; and no greater effect followed 
the compression of both carotids. The artery was tied at the 
middle of the neck, after a somewhat tedious dissection, owing 
to the cedematous state of the tissues. A slight oozing of 
blood continued ; but it was easily arrested by forcing a piece 
of sponge deep into the wound in the direction of the bleeding 
vessels. On removing the patient to her bed, it was noticed 
that the side of the body opposite to that upon which the artery 
had been tied had become completely paralyzed. The paraly- 
sis gradually diminished as the strength of the patient im- 
proved ; and, on the 14th of May, the ligature of the carotid 
came away. The sponges had been previously removed from 
the Avound, which healed rapidly. An abscess, which formed 
behind the ear, did not delay the cure ; and, on tlie 24th of 
May, the patient was discharged, cured, but still somewhat 
feeble. 



80 THE FACE. 

It should have been remarked, that, prior to commencing the 
operation on the jaw, it had been decided to uncover the tumor, 
and, if the cyst was found but partially to occupy the bone, to 
remove a portion of it without removing the whole bone. It 
was evident, however, as soon as the tumor was exposed, that 
all the bony tissue had disappeared ; and its place had become 
occupied by a thin and almost transparent cyst, of the consist- 
ency of parchment, the coronoid and condyloid processes mak- 
ing a part of it. The removal of the whole bone was therefore 
performed. 

The eiFects of the ligature of the carotid were quite remark- 
able. The current of blood was sufficiently checked to .allow 
of effectual plugging, which before would not stem the cur- 
rent of blood. The effect on the brain was certainly very 
singular. A hemiplegic affection, three or four days after the 
ligature of the carotid, is not uncommon ; arising, probably, 
from an inflammatory action taking place in the substance of 
the brain. In the present instance, the paralysis was immedi- 
ate, and must have arisen from the sudden diminution of the 
supply of blood to the brain, following upon the great drain to 
which the system had been subjected a few days before. 

The patient has been heard from lately, having perfectly re- 
covered her health. 

Cancerous Tumors. — Cancerous tumors of the jaw pre- 
sent all the characteristics of that growth as seen elsewhere ; 
nor are they very rare. They are more frequently found in 
connection with the upper than the lower jaw, and generally 
commence in the antrum. Being concealed within the bone, 
they often make their way into the nasal passages, and increase 
to a considerable size before they appear through the bone ex- 
ternally ; and for this reason it is difficult in the earlier stages 
to decide whether the disease is malignant : when, however, the 
tumor has protruded beyond the walls of the antrum, and when 
it is situated in the lower jaw, the diagnosis is less difficult. 

Two or three cases are or-iven in illustration : — 



CANCEROUS TIBIORS. 81 

Case XLYII. — Removal of the Upper Maxillary Bone, 
— Mrs. G., aged 49 years, applied to me in September, 1857, 
for a tumor of the left upper jaw-bone. She was a small, 
thin woman, of a delicate constitution, and somewhat sallow 
complexion. She knew of no hereditary disposition to cancer. 
She was the mother of several children. 

For three years she had perceived a fulness of the cheek- 
bone, and there was at the same time a slight and constant 
discharge from the nostril of that side. This continued, and 
the swelling increased, until July, 1857, when she suffered so 
much from it, that her physician punctured the antrum, after 
having extracted a tooth. At the time there was a slight hem- 
orrhage ; but three days afterwards a copious discharge of pus 
took place, which continued in varying quantities. When the 
discharge was small, there was much fulness and pressure about 
the antrum, which was relieved by an increased flow. 

The whole upper jaw-bone seemed to be enlarged. The 
tumor had not made its way into the mouth, but seemed dis- 
posed to do so into the cheek, the integuments of which were 
reddened and a little oedematous. I advised an operation as 
affording the only chance for relief from suffering, though its 
ultimate success was doubtful ; letting her and her friends 
understand fully its advantages and disadvantages. It was 
decided that the operation should be done. 

It was performed in the usual manner, as has been before 
related, the palatine bone and soft palate being preserved. In 
depressing the bone after its attachment had been divided, a 
portion at its posterior part was found adherent, and was left 
attached to the pterygoid process so as to requii'C removal by 
the chisel. This circumstance I have, once or twice, seen 
happen in removal of the superior maxillary bone ; the natural 
adhesion of the part being almost increased to anchylosis by the 
inflammatory action, which had been going on in its neighbor- 
hood. It is of so frequent occurence, that it might be well in 
every case, as recommended by Dr. J. C. Warren, to pass a 
chisel behind the bone, and loosen it by two or three blows of 
the mallet. 

She had a very good recovery, and returned home about three 

11 



82 THE FACE. 

weeks after the operation in good health and spirits. She con- 
tinued well for a time, but has, I believe, since had a return of 
the disease. 

Case XL VIII. — 3Ialignant Disease of the Upiier Jaiu. 
Removal. — In April, 1859, Mrs. N. M. applied to me for a 
tumor which had existed about ^yq months. It commenced 
a few weeks before the birth of a child. The tumor occupied 
nearly the whole of the upper maxillary, pressing down the 
palate, extending from the root of the canine back to the last 
molar. Externally, the swelling extended quite back to the 
ear. The whole bony margin of the orbit was lost, and its place 
supplied by an irregular swelling. The pupil was turned up- 
wards. No tumor could be perceived in the nostril. The skin 
over the tumor was movable, but tense and glossy. There 
being no doubt in regard to the malignant nature of the disease, 
an operation was decided upon. 

The incisions were made a little differently from those I have 
usually practised, on account of the extension of the disease so 
far backwards. The first incision commenced midway be- 
tween the orbit and auditory passage, and extended in a semi- 
circular form to the angle of the mouth, with a very broad, 
backward sweep ; instead of commencing just back of the orbi- 
tar process of the superior maxillary. In depressing the bone, 
after the usual divisions, the fingers were used, as it was so 
degenerated by the disease as not to allow a firm hold with for- 
ceps. After removal, it was found that the cancer had pene- 
trated into the pterygoid fossa. This was scooped out with the 
fingers, and a hot iron applied. 

The eye regained its natural position, and the wound healed 
without unpleasant symptoms. In a fortnight she left the Hos- 
pital, and returned home. 

Case XLIX. — Removal of half of Lower Jaio for Can- 
cer. — James W., 56 years of age, ap23lied to me in the early 
part of September, 1859, for a tumor about the size of a hen's 
Qgg, occupying the angle and horizontal part of the right side 
of the lower jaw. The disease had commenced twelve years 



CANCEROUS TIBIORS. 83 

previously, with a numbness in the jaw, followed by swelling. 
Three years before, the pain in it became excessive, when an 
opening was made with a lancet, and a discharge of fluid took 
place, attended with relief. 

When I saw him, the outlines of the jaw had disappeared ; 
and the place was occupied by a smooth, round, shell-like tumor, 
which extended from the canine tooth backwards, rising a little 
upon the ramus of the jaw. The tumor projected inwards, press- 
ing upon the tongue, lifting up the palate, and obstructing about 
one-third of the aperture of the fauces. His health was pretty 
good. He suffered principally from the obstruction to deglu- 
tition, and the affection of the voice. The disease thus far did 
not seem to have invaded the soft parts. 

There appeared, therefore, to be no question as to the pro- 
priety of its removal : the only doubt was, whether to remove 
the jaw at the articulation, or saw off the bone just below. The 
principal objection to disarticulation, where the tumor is large, 
is the division of more or less of the filaments of the facial 
nerve. The objections to sawing off the bone in its ascending 
ramus, given by some surgeons, is, that the remaining fragment 
is drawn forward by the pterygoid muscles, and afterwards pro- 
duces irritation. This I have not found to hold good in practice. 
In this case it was decided to disarticulate, the operation being 
performed as in previous cases. While continuing the dissection, 
however, after the facial artery had been cut and tied, it was cut 
a second time, although the incisions were not carried any fur- 
ther below than before. The tumor had lifted it out of place. 
I mention this fact to show how the best concerted plan may 
be frustrated by the anatomical displacement of the parts, in- 
duced by the growth of tumors in their neighborhood. The 
flow of blood was arrested at once : the patient became quite 
faint, and was obliged to be placed in the horizontal position for 
a few moments. This is worth mentioning, as it so rarely 
occurs in the course of surgical operations where the patient 
is kept up by the stimulus of the ether ; and, previous to the 
introduction of that agent, it probably occurred as often from 
the exhaustion of the system by pain, as from the loss of blood. 
The separation and disarticulation of the diseased portion was 
completed as usual. 



84 THE FACE. 

He had scarcely a bad symptom ; and the wound was ahnost 
entirely healed at the end of two weeks, when he left town. 

On making a section of the tumor, with the saw, the jaw 
was found expanded into a shell, the contents being a soft gray 
matter. 

It may be worth mentioning, that, in depressing the jaw for 
disarticulation, although done with great care, the ramus partly 
gave way in the tumor ; against which occurrence a caution is 
given in some works on surgery. The facial nerve, and, so 
far as could be ascertained, the parotid duct, seemed to have 
escaped the incisions ; the dissection for the disarticulation of 
the bone being made as far as possible from the inside, after the 
tumor was sufficiently freed from the soft parts. 

Fibrous Tumors. — Fibrous tumors on the jaw are rare, 
though they occur here more frequently than on other bones. 
As described by Paget, they are round or oval, lobulated, dense, 
and heavy. They are almost uniformly white, and occasionally 
contain minute spiculaa of bone. 

Case L. — Removal of the Upper Maxillary Bone for 
Fibrous Tumor. — In the summer of 1857, I was requested 
by Dr. Edward Reynolds to visit with him, in consultation, a 
patient who was suffering from an affection of the left upper 
jawbone. Some months before, the disease had commenced by 
an irritation in the neighborhood of the left lachrymal passage, 
which produced an obstruction and an overflow of tears. This 
was followed by an increase in size of the upper maxillary bone : 
finally, an aperture appeared in the alveolar process of one of 
the molar teeth, through which there was a discharge of blood. 

In the left nostril, there was a polypoid tumor ; and there had 
been one or two bleedings from this point. A probe was passed 
into the opening in the mouth, which penetrated deep into the 
maxillary sinus, and was followed by a free discharge of blood. 
The patient being rather low in health, and proposing to make 
a visit to her friends in Maine, I provided her with instructions ; 
and she aoTced to see me asrain in the course of three or four 
weeks. 



FIBROUS TUMOKS. 85 

At the expiration of the time appointed, she returned to Bos- 
ton, improved in health. The tumor in the nostril, however, 
had increased , as well as the distention of the maxillary sinus ; 
and she had suffered from one or two severe hemorrhages. 
Durino; the followino: week, a bleedino- of so severe a nature 
took place, as to render it necessary to have some active sur- 
gical procedure at once adopted. 

Before making my decision, I passed a finger into the nostril, 
which disclosed a large opening into the maxillary sinus, from 
which the tumor in the nose seemed to have projected. The 
jaw, in the neighborhood of the aperture in the mouth, had, 
since the last examination, three weeks before, been more or 
less forced downwards into a rounded elastic tumor. These cir- 
cumstances left little doubt that the maxillary sinus was occu- 
pied by a tumor which was gradually forcing itself out from the 
bony cavity in which it had originated. I advised, therefore, 
all immediate operation. 

The operative procedure was as usual, and occupied about ten 
minutes. The hemorrhage was not excessive, and the vessels 
were easily secured. The edges of the wound were at once ap- 
proximated by sutures; and a bit of lint, moistened with cold 
water, laid over the surface. 

No lint, bits of sponge, or other substances, as recommended 
by some of the French surgeons, for filling up the cavity made 
by the removal of the jaw, were used in this, or the other cases 
in which I have done the operation. Whenever I have seen 
them used, they have been the source of much irritation, have 
been with difficulty removed, and have caused a most offensive 
odor, from the retention of foul secretions in the mouth. 

She recovered fully and entirely ; and now, at the end of 
nearly nine years, I have heard of her in the enjoyment of good 
health. The eye suffered no injury from the operation. 

The tumor was of a fibrous character, and was completely 
bounded by its capsule. In its expansion, it had at first nearly 
obliterated the lachrymal passage ; next, it had produced an 
absorption of the bone, in the vicinity of the nostril, forcing its 
way through into that cavity ; and, finally. It was making 
its way downwards through the bone into the back part of the 
mouth. 



S6 THE FACE. 

The operation was as effectual and satisfactory in its result as 
any one of this description that I have ever done or witnessed. 

Apparent Tumors of the Lower Jaw, secondary to 
THE Removal of Cancer of the Lip. — It is sometimes 
necessary to remove a part of the jaw for other diseases than 
tumors of the bone. Tumors which take their origin in the 
vicinity of the bone sometimes grow around and envelop it so 
as to necessitate its removal. 

After having examined a firm and apparently osseous tumor 
of the lower jaw, and after having fully decided on an operation 
for its removal, I have often been surprised to learn that the 
patient had, a year or two before, been operated on for cancer 
of the lip. On critically questioning him, I have discovered 
that the tumor had originated, not in the jaw itself but under 
it, in the position of the submaxillary gland, and increased, 
until finally, embracing the bone and becoming adherent, it 
could not be distimmished from the bone itself. 

o 

Case LI. — Tumor similating Ca7icerous Disease of the 
Parotid, accoonj^aiiied with Paralysis. — I have been lately 
consulted by a gentleman who had a hard tumor growing just 
behind Ms ear, of a year's standing. It extended under the 
jaw ; was very firm, almost like bone ; and appeared to be 
the parotid in a state of malignant disease. The side of his 
face was paralyzed ; and also, curious to relate, there was a 
slight paralysis of the left arm, the tumor being on the right 
side of the body. I found, on investigation, that a few months 
before the commencement of the present tumor, a cancer of the 
lip, of some years' duration, had been removed from the left 
side. 

Case LII. — Tumor, involving the Jaw, occurring after 
Removal of Cancer of the Lip. — A gentleman Qd> years of 
age was politely referred to me for advice, by Dr. Gilman, 
of Portland, for a tumor about as large as a small orange, grow- 
ing from the lower and outer edge of the jaw, on the left side, 
concealing the angle, and extending backwards so as to press 



TUMORS SECONDARY TO CANCER OF LIP. 87 

upon the great vessels of the neck, and partially to interfere with 
the trachea. The inner aspect of the jaw was quite normal, and 
the teeth w^ere evidently not involved. It felt like an exostosis, 
and had the regular form characteristic of a cystic tumor of 
the bone : it was, however, perfectly firm, and had none of the 
elasticity of the latter kind of growth. I had settled, in my 
own mind, that it was of a bony nature, when the patient told 
me that it had begun, about a year before, as a small, movable 
tumor in the situation of the submaxillary gland ; and that it 
had not become fixed until after eight months, and had then 
taken on a rapid growth. He also said, that, four years 
before, he had submitted to a prolonged operation, by means of 
cancer plasters applied daily for several weeks, for a cancer 
of the lip, of which a scar still remained rather to the right of 
the median line. On ascertainiuGr this fact, the tumor was ao-ain 
examined ; and it was found, that, by exerting much force, a 
slight movement upon the jaw could be produced. The patient 
was therefore informed, in as delicate a manner as possible, of 
the nature of the disease, and that an operation might be per- 
formed for the removal of the tumor, either alone, or with a 
portion of the jaw, which would be a much less difficult and 
bloody affair : the danger of recurrence would of course remain. 
He wisely concluded, however, on account of his age and his 
entire immunity from pain, as well as from the danger of recur- 
rence, not to have it interfered with. 

Case LHI. — An old gentleman, 75 years of age, Avas 
brought to the Massachusetts General Hospital, with a tumor 
of the right side of the horizontal part of the lower jaw, of 
about the size of a pigeon's egg. It was firmly attached, and 
seemed to form a part of the bone, and so far painful as to in- 
duce him to request its removal. It had commenced at the 
lower and inner edge. Upon inquiry, I found that he had been 
operated on for cancer of the lip a few months before the 
growth had appeared. I informed him of the probable nature 
of the disease, and of the danger of recurrence after removal. 
He decided to have an operation performed. Accordingly, 
the portion of jaw involved in the tumor was removed. The 



00 THE FACE. 

disease, on examination, was found to be cancerous, and firmly 
embraced the bone, although by careful dissection it could be 
entirely separated from it, including, however, the periosteum. 
The termination of this case was interesting. After the pa- 
tient had recovered from the ether, he got up and insisted on 
walking downstairs, which he did with the aid of two persons, 
one on each side of him. Just as he arrived at his bedside, he 
became suddenly faint. The attendants came running upstairs, 
and informed me that the patient was in a dying state ; and, on 
going instantly to him, I found that respiration had ceased, and 
that the pulsations of the heart were scarcely perceptible. The 
mouth was immediately opened, and the finger passed down the 
throat, in order to allow the entrance of air into the larynx : 
it was then found that the tongue had become retro verted from 
the partial detachment of some of its muscles, and had retracted 
down the throat. It was at once seized with forceps, and drawn 
out of the mouth, and means taken to produce artificial respi- 
ration, as in cases of drowning ; and eventually respiration and 
the circulation were restored. The patient did well for a time ; 
but, at the end of about a week, he was seized with thoracic 
symptoms of which he died. 

Necrosis of the Jaw. — Necrosis of the jaw-bone is 
sometimes caused by arsenious acid, used to destroy the nerve 
of a tooth ; at others, by phosphorus ; also by the depressing 
effects of cold ; and now and then we see it occur without any 
specific cause. 

The use of arsenic, introduced into the cavity of a carious 
tooth, has been very extensively followed, for the purpose of 
producing a slough of the pulp, and thus admitting of the 
subsequent preservation of the tooth by filling. Unless care- 
fully protected by mixture with morphia, to dull sensibility, 
the pain is often of the most excruciating character ; but, with 
the benumbing effect of this agent, the escharotic action goes 
on, in many cases, unheeded. In one or two instances in 
which this agent has been used, and allowed to remain 
for too great a length of time, or else from some peculiarity 
of constitution, principally in persons of scrofulous diathesis 



NECEOSIS OF THE JAW. 89 

and of low vitality, I have seen very severe effects produced ; 
the cauterizing action not only destroying the vitality of the 
tooth, but going farther, possibly by absorption, and producing 
extensive necrosis of the alveolar processes, almost as great in 
the upper jaw as we see in the lower from the effects of 
phosphorus. In one case, a delicate young lady, whom I saw 
in consultation with Dr. N. C. Keep, of Boston, to whom she 
had applied for advice, had suffered extensive destruction of the 
alveolar processes of one side of the upper jaw, caused, as was 
supposed, by arsenic applied by a dentist and left too long in the 
cavity. The following case I saw in consultation with Dr. E. 
T. Wilson, Jan. 3, 1865. 

Case LIY . — JSFecrosis of Upper Jaw arising from the 
Use of Arsenious Acid, — A young married lady, of scrofulous 
habit, had arsenic introduced into the right bicuspid tooth of 
the upper jaw, where it was left over night, causing great suf- 
fering. The tooth had been afterwards filled, but was always 
the source of more or less uneasiness. About three years after, 
she had a Ions: and debihtatino^ illness, at the end of which she 
found that this tooth, together with one or two of its neigh- 
bors, was quite loose, — so loose, in fact, that she removed them 
with her fingers. On applying to Dr. Wilson, he found that 
the alveolar processes were in a state of necrosis, and requested 
my advice with regard to an operation. The gums had receded 
quite extensively, leaving a large piece of jaw dead, and in a 
most ofiensive condition. On seizing the bone, I found it so 
firmly fixed that I advised against any immediate operation. 
Dr. W. agreed to give her a detergent wash of tannin and 
creosote, and to await the farther loosening of the bone. I 
afterwards learned that it separated piecemeal. 

Dr. Wilson informs me, that, whenever he uses the arsenic, he 
always applies it in the morning, so as to watch its action, and 
removes it before night ; most of the accidents having been 
caused by applying it one day, and allowing it to remain until 
the next before removal. 

In another case, a young lady had a bicuspid tooth filled by 
a dentist, the nerve having been first destroyed by arsenic left 

12 



90 THE FACE. 

in over night. Six months after, her face swelled, and an ab- 
scess formed at the root of the tooth which was extracted, 
the alveolar process coming out with it in a state of necrosis. 
Afterwards other pieces of bone came away from the jaw in 
the vicinity. 

Her face looked puflfy ; and she had constitutional symptoms, 
such as swelling of the abdomen, and great loss of strength. 
Many of the teeth in the upper jaw became so loose that they 
might have been extracted with the fingers. She was a very 
handsome person, of fine physical development, and had a 
beautiful set of teeth ; and, before the use of the arsenic, had 
always had good health. 

I have seen other similar cases ; but those given above will 
serve to illustrate the affection. 

Case LV. — Necrosis of half of Lower Jaw from Phospho- 
rus. — A young woman, 19 years old, entered the Hospital on 
the 29th February, 1860, for necrosis of the jaw of ^yQ months' 
standing. She had been an operative in a match factory for two 
years, and her employment was to pack the matches in paj)er. 
Five months before, an abscess formed under the posterior part 
of the jaw, behind the angle ; and, from this spot, there was a 
discharge of offensive pus. Denuded bone was detected in this 
situation. On the 7th of March, she was etherized ; and a bit 
of bone an inch long, and two smaller pieces, were removed. 
On the 25th of April, she was again etherized, and the cheek 
laid freely open, exposing most of the jaw, which was found 
completely dead but firm. On the 30th of May, a final opera- 
tion was performed. The bone was firmly seized by a powerful 
pair of forceps, worked gently, for some time, to and fro ; and, 
finally, a portion of the body and the whole of the ramus were 
removed. On the 17th of June, the wound was closing rapid- 
ly ; and new bone was found to be forming in the place of that 
which had been lost, the processes being well marked. This 
patient remained some time afterwards in the Hospital, acting 
as nurse. The Avound gradually healed, and she was left with 
quite a well-formed jaw, serviceable for all purposes. I sub- 
sequently saw her, some years afterwards, in the full enjoyment 
of health. 



NECROSIS OF THE JAW. 91 

Case LVI. — Necrosis of the Lower Jaw, from the Effects of 
Cold. — A young lady 25 years of age, in moderately good 
health, about the middle of September, 1859, walked over 
South-Boston Bridge with her face exposed to a very high wind. 
Almost immediately, she began to feel an uneasiness in the 
right side of the lower jaw. This increased, accompanied with 
swelling of the gum. After some weeks, the second molar 
tooth was removed, being completely loosened and detached 
from its socket. The disease extended forward. At the same 
time, the left knee began to swell, and a copious eiFusion of 
serum took place into the joint. 

At the time of my visit, I found her confined to the sofa by 
the trouble in the knee, and in a very nervous and highly ap- 
prehensive condition. On examination of the jaw, the canine 
tooth and those behind it, with the exception of the last molar, 
were loose. Passing^p probe into one of the numerous openings 
which existed in front, the alveolar portion of the jaw was 
found denuded ; and the probe, at one point, passed quite 
through it. A slight swelling appeared below the jaw. 

As she was suffering no pain, and the bone was still quite 
firm, I did not advise any immediate operation. She was recom- 
mended to take wine, and as much nourishment as the stomach 
could well bear, consistently with her confinement, and to have 
an attempt made to remove the dead bone as soon as it seemed 
loosened from its attachments. 

This was afterwards done by her physician, and she completely 
recovered. 

Case LVU. — Necrosis of Lower Jaw, from Exposure to 
Cold, while tender great Mental Depression. — A man 49 years 
of age entered the Hospital, March 10, 1866, with a necrosis 
of the right side of lower jaw, extending from beyond the 
symphysis to the angle. 

Inflammation and swelling had commenced in the jaw, after 
exposure at a funeral, while suffering from want of food, and 
under great mental depression. Most of the teeth had dropped 
out, there was a very offensive discharge, and his health was 
much affected. 



92 THE FACE. 

I removed the whole of the jaw in a necrosed state, leaving 
the periosteum at the sides, and a thin rim of new-formed bone 
on the lower edge. 

The incisor teeth remained loose in the gums, their roots pro- 
jecting into the cavity left by the removed bone. 

I saw this man on the last of May, entirely recovered. New 
bone was deposited in the place of the old, which he could use 
in the mastication of moderately hard substances. * The incisor 
teeth had become pretty firmly fixed in their places. 

THE TONGUE. 

Case LYIII. — Encysted Tumor under the Tongue, re- 
sembling Ranula. — The tumor under the tongue called ranu- 
la, whether it be a dilatation of the salivary duct or a distinct 
tumor, is always troublesome in treatment. I tried, for a 
number of years, Dupuytren's method of a permanent button, 
which, though effectual, has the disadvantage of requiring to 
be permanent. Perhaps excision of a portion of the sac, and 
the free application of the tincture of iodine to the interior, 
if this be found necessary, is as good as any practice. The 
following case of tumor under the tongue is interesting, as 
resembling this disease, which I have frequently seen of great 
size, and forming a tumor on the side of the neck. It was, how- 
ever, in this case, placed in the median line, and, as soon as the 
operation was commenced, was found to be a diiFerent affection. 

When I first saw this patient, on opening his mouth, it 
seemed to be entirely filled with a greatly enlarged tongue. 
On farther inspection, the tongue was found crowded into the 
back part of the fauces. An elastic tumor occupied the mouth, 
and extended beneath the jaw, appearing in the neck. The 
patient was 25 years of age, a painter by trade ; and the tumor 
had been of seven years' growth. 

This large sac was completely dissected out, with slight 
hemorrhage. Its contents were acid, white colored, and of the 
consistence of cream. An inflammatory action followed, pro- 
ducing hoarseness and difficult deglutition : this lasted a week 
or ten days, and he was entirely well at the end of a fortnight. 



THE TONGUE. 93 

Case LIX. — Cancer of Tongue, HemovaL Recurrence, 
Death, — A gentleman, 30 years of age, called on me about 
the year 1850, on account of a white film under the back part 
of his tongue, on the right side. It had the appearance of 
mucous membrane which had been touched by nitrate of silver, 
and turned white ; but the edges were more perfectly defined. 
He was nervous about it and wished its removal, fearing that it 
might become cancerous. I dissected it carefully off from the 
tongue ; and he had no trouble for a number of years. In 1855, 
on my return from abroad, I found a small ulcer at the spot 
from which the disease had been removed. He did not send for 
me till about six months afterwards, when the tongue was solidly 
fixed, and pervaded by a cancerous infiltration. He was in a 
most deplorable condition : the saliva was constantly running 
out of his mouth, deglutition was difficult, and the pain at times 
very severe. The disease gradually extended down his throat, 
and finally opened a large-sized vessel, when a profuse hemor- 
rhage occurred, which was checked by a gargle of a strong solu- 
tion of perchloride of iron. He was gradually exhausted by 
loss of blood, and finally died in an anaemic condition. 

This case is curious from the manner in which it commenced, 
without ulceration and as a simple white deposit. I have lately 
seen another case with white deposit on one side of the mouth, 
and extensive cancer of the gums on the other, brought on by 
excessive use of tobacco. In regard to operations for cancer 
of the tongue, I can simply say, they are generally unsuccess- 
ful. As to the method of operating, I formerly used ligatures, 
rarely the knife ; but of late years the ecraseur. 

Case LX. — Solid Encysted Tumor of the Tongue. Re- 
moval, — Oct. 12, 1847, a physician of Worcester brought 
to my house a patient with a tumor on the end of his tongue. 
It was about as large as a filbert : on the tip was an ulcer the 
size of a pea. The tumor was first noticed seven weeks before, 
and the ulceration two weeks. There was no pain nor tender- 
ness. 

Passing a pointed knife behind the tumor, I made an incision 
around the left side, when the pressure of the knife caused the 



94 THE FACE. 

escape, through the ulcerated aperture, of a solid red substance, 
like a small cherry. The operation was completed by an in- 
cision on the right side, by which a cyst was removed, with a 
small portion of the tongue. 

The cyst resembled those so frequently met with in the sub- 
stance of this organ. The solid tumor appeared to be organized, 
and not malignant ; yet its connection with the enclosing cyst 
must have been very slight, as a moderate pressure expelled it. 

A stitch was employed, and the patient went home the same 
day. He had been in the habit of chewing tobacco. 

In another instance of a solid tumor situated in the centre of 
the tongue, a simple incision was made over the top of it, when 
a small, hard, fibrous tumor was shot out, having, apparently, 
scarcely any connection with its envelopes. 

I have also seen a tumor, in this situation, apparently of a 
fatty nature. 

SALIVARY CALCULUS. 

Case LXI. — Interesting Case of Salivary Calculus. — 
An English gentleman, 40 years of age, applied to me, in 
August, 1859, on account of a very painful enlargement and 
inflammation of the left submaxillary gland, attended with an 
abscess behind it, which discharged through the duct under the 
tongue ; a small quantity of pus also escaping through the 
gland and integument. The inflammation of the gland came on 
two years before, after exposure to cold. Subsequently, and 
after much suflering, two small calculi were extracted from the 
duct in the mouth. This gave temporary relief. The pain 
however, in the gland and whole of the /leck, continued, some- 
times of the most agonizing description ; aflecting the system, 
and keeping him from his employment. Applications of iodine 
and other remedies had aflbrded no relief. 

It was with great difficulty, that the aperture in the mouth, 
through which the pus was discharged, could be brought into 
view, as it lay far back, and was obscured by the tongue ; but 
by placing him in a strong light, holding the tongue to one 
side, and requesting him to press the gland up, pus was seen to 



SALIVARY CALCULUS. 95 

issue from it. A probe was insinuated into this opening ; but it 
was not of sufficient size to serve as a guide to the knife. An 
incision downwards was therefore made close to the jaw, until 
the pus flowed freely. This opening shortly closed up, and the 
operation required to be repeated. In the mean time, it was 
impossible to make the slightest examination of the gland exter- 
nally, the touch of the probe gave such exquisite pain. 

Under the influence of ether, a semilunar incision was made 
over its surface, exposing the indurated and highly inflamed 
gland. The blood gushed out at once from the whole surface, 
obscuring it, and requiring some delay in the dissection. A 
small aperture was found at some distance from the opening in 
the skin, which would admit a fine probe into an almost callous 
canal beneath the gland. With much care and great difficulty 
the size of the probes was gradually increased, until a director 
could be introduced. This being a little curved, and turned 
in an upward direction, encountered a resistance which at first 
appeared to be bone, but was finally ascertained to be a calculus. 
A finger was introduced into the throat and under the tongue, 
and pressure made on the outside ; but no hard substance could 
anywhere be distinguished. The only means left, therefore, 
seemed to be by penetrating to it through the hard deposit. By 
careful touches of the knife, and dilatation with the scissors, 
an aperture was finally made large enough to admit of the intro- 
duction of a small pair of polypus-forceps, by which the stone 
was broken up, and withdrawn piecemeal. The enlargement of 
the aperture by the scissors, by introducing them shut and with- 
drawing them partly open, was followed by a gush of blood, 
which continued to flow for some time, as if from the wound 
of a large vessel ; and, it being impossible to reach the deep 
origin of the bleeding, a bit of sponge was crowded down into 
the cavity, as soon as the calculus was removed, and arrested the 
flow of blood. This being removed, after a few minutes 
the bleeding recurred, but suddenly stopped. As a matter of 
precaution, and in order to keep the wound open to permit a 
free discharge, the sponge was replaced. 

From this time he gradually recovered ; and now, at the end 
of seven years, remains well. 



CHAPTEE III. 
THE NECK. 

FOREIGN BODIES IN THE AIR-PASSAGES. 

Dr. Gross, the distinguished Professor of Surgery in the 
University of Pennsylvania, and surgeon at the Pennsylvania 
Hospital, has done more than any other person, in his w^ork 
vs^ith the above title, to illustrate this subject, as he has all 
other subjects in surgery. 

It is well known, that operations on the trachea are always of 
a startling character, and require great skill and prompt action 
on the part of a surgeon, to save life ; whether it be for the re- 
moval of a foreign body, for croup, or for the other inflam- 
matory affections of this organ. 

In the latter instances, the surgeon is often called upon, 
without any previous preparation, possibly in the middle of 
the night, without assistance, and with a bad light, to perform 
one of the most critical operations in surgery ; the patient gasp- 
ing for breath, and dependent on the exertion of the utmost 
skill for life. 

From the great difficulty in respiration, the neck is generally 
crowded with venous blood, the free flow of which obscures the 
incisions ; and, on the trachea being opened, it is apt to rush 
into the air-passages, and suflbcate the patient. If the surgeon 
hesitates, on the other hand, and waits to secure the vessels, 
death may occur before the trachea is reached. Fortunately, 
in most instances, as soon as the air enters freely into the 
lungs, the congestion in the veins is relieved, and the bleeding 
ceases. 

The diagnosis of the existence of a foreign body in the trachea 
or in the bronchus, although at first it would seem not to be 



FOREIGN BODIES IN THE AIR-PASSxVGES. 97 

attended with much difficulty, is often very obscure. This is 
particularly the case in young infants, and in children of 
four or five years of age. On its first introduction, there is 
usually great choking, and violent irritation of the air-passages. 
After a time, however, if the substance sink down into the 
lungs, these symptoms disappear; and it is then necessary 
to look for another class of phenomena upon which to base 
an opinion. These consist, in the first place, of dulness on 
percussion of the afiected side; second, of more or less dim- 
inution of the respiratory murmur, according as a larger or 
smaller bronchial tube is obstructed ; third, of more or less 
bronchial and subcrepitant rales ; but these may be observed 
equally on the sound side of the chest, being provoked by the 
general irritation of these oro^ans. The diao-nosis becomes 
more difficult where the patient has had a previous bronchial 
disturbance, or has been exposed to the whooping-cough or 
measles, all of which complications I have had occasion to wit- 
ness. The importance of a correct diagnosis is very great ; for, 
if an operation be deferred, the substance may suddenly be 
started from its hiding-place, and driven up into the glottis, 
causing death before any help can be obtained. 

The following pages contain the substance of remarks on this 
subject, in a condensed form, published in the " Boston Medi- 
cal and Surgical Journal" for 1847, and referred to in Dr. 
Gross's valuable work, with additional cases : — 

Case LXII. — Bean in the Left Bronchus. — On Tues- 
day evening, Oct. 13, 1847, I was called to see a little girl, 
eight years old. The same morning, while laughing, a common 
garden bean was drawn into the trachea. At first she was 
nearly suffocated. Gradually the cough and struggles became 
less violent ; and during a ride of four or five miles almost 
entire tranquilhty in the respiration was restored. After an 
hour or two the difficulty of breathing returned, and finally 
became so laborious that the parents, being alarmed, deter- 
mined to bring her immediately to Boston. 

I saw her at 7 o'clock, p.m. The countenance was pale, 
rather livid, and expressed great anxiety. On any change of 

13 



98 THE NECK. 

position, a cough was produced, attended with the ejection of a 
quantity of mucus. On auscultation of the back of the chest, 
the sound of the natural respiration was much obscured by a 
loud mucous rale : in front, the rale was very loud on the right 
side ; but, on the left, the sounds of respiration and the rales 
were, in a great measure, wanting. On percussion, the left side 
was a little flatter than the right. There was no sound, either 
in the lungs or trachea, to indicate the movement of a foreign 
body. The voice was husky, as in croup. 

In view of the above symptoms, I had no doubt that the 
foreign body was lodged in the left bronchus, and advised 
the following course : First, in order to ascertain if the sub- 
stance was movable, and likely to ascend towards the larynx, 
that the child should be suspended with the head downwards, 
the throat irritated, and percussion made on the chest. Second, 
if the substance could be made to fall into the trachea by these 
means, to perform the operation of tracheotomy. 

The first proposal was carried into effect. The child was 
taken by the legs, and held with the head downwards ; then, 
passing my finger into the throat, I carried it quite below and 
behind the epiglottis, so as to induce strong efforts to vomit. 
Percussion of the chest was also practised. 

The process above described was twice repeated without avail. 
A great quantity of mucus was brought up by coughing ; but 
no strangulation was induced, nor other symptom to indicate a 
change of position in the foreign body. Quiet was now en- 
joined, and an opiate in case of great irritation. 

The following night was passed quietly, and only disturbed 
by one fit of coughing. These attacks were produced by the 
slightest mental or physical excitement. The rales were slightly 
increased. 

In consultation, it was concluded as follows : — 

1st, That the great want of success attending the operation 
of opening the air-passages, and searching for foreign bodies, 
arising from the irritability of the parts, and the consequent 
difficulty of manoeuvring instruments, did not render an imme- 
diate operation desirable, particularly as the patient was com- 
paratively easy, and the danger not pressing. 



FOREIGN BODIES IN THE AIR-PxVSSAGES. 99 

2cl, That the spontaneous expulsion of these bodies was not 
unusual. 

3d, If symptoms of strangulation came on, to operate imme- 
diately. 

It was determined to give the child an emetic of ipecac, as 
considerable febrile action was present, and the effort of vomit- 
ing might possibly move the foreign body. This was done with 
much relief to the breathing, but without causing any change in 
the situation of the substance. 

On the morning of the 15th, I found her quite as comfortable 
as on the day previous. 

About 4 o'clock in the afternoon, I was called in haste. In a 
paroxysm of mental excitement, produced by the mother's taking 
leave of her, the bean was suddenly disengaged, and brought 
on strangulation. When I arrived, she was almost exhausted ; 
the face was livid, and she was writhing in distress, like a person 
having a cord tied tightly around the neck. 

I immediately proceeded to open the trachea. The skin and 
superficial fascia being divided, and the thyroid plexus of veins 
avoided or tied, as I was separating the sterno-hyoid and sterno- 
thyroid muscles, a sudden crack was heard, as if some portion 
of the lung had given way. This was immediately followed by 
an emphysema of the cellular membrane in the neighborhood of 
the wound ; and a small tumor, filled with air, was forced up 
out of the chest, on the left side and in front of the trachea, at 
each movement of inspiration. A mitigation of the distress in 
breathing followed this occurrence. The tumor was now held 
back with a spatula, and a sharp-pointed bistoury plunged 
into the trachea. The bean was seen greatly swollen, moving 
up and down in the tracheal passage, and completely filling- 
its calibre. The edges of the trachea being separated, the 
bean was seized with some difficulty, on account of its soft- 
ness, and withdraAvn. She immediately, on the conclusion of 
the operation, fell into a most profound sleep. 

The bean had swollen to more than double its original size. 
On measurement, it was ascertained to be two-thirds of an inch 
in length and half an inch in breadth. 

The patient recovered witliout any bad consequences. 



100 THE NECK. 

Remarlcs. — The rupture in the air-passages did not present 
any subsequent symptoms which could be referred to these or- 
gans, and therefore there must be some hesitation in deciding 
upon the seat of this accident. In all probability, it took place 
at the root of the luns^ in one of the laro-er bronchial tubes, 
and the air made its way out of the chest without implicating 
the pleural cavity. A similar rupture I once before observed 
in croup, — the neck and whole side of the chest becoming 
emphysematous, with an immediate relief to the breathing, 
as in the present case. 

Subsequently, having procured some garden beans of a simi- 
lar kind to the one removed, I immersed them in water of the 
temperature of the body and found that in forty-eiglit hours 
they were increased in bulk to more than double, and some to 
treble, the natural size. This shows that when substances which 
may become enlarged by the heat and moisture of the body are 
introduced into the air-passages, no hope can be entertained of 
their spontaneous expulsion. In such cases, operation should 
not be delayed. 

I saw this patient fifteen years afterwards, grown to a large, 
fine-looking woman. She had never experienced any incon- 
venience from the effects of the accident or the operation. 

Case LXIII. — Horse-shoe I^cdl in the Bronchus. Spon- 
taneous Expulsion. — On May 10, 1846, a little boy, be- 
tween two and three years old, was brought to me with a nail 
in its lungs. The account given was as follows : — 

Three weeks before, the child came into the house from a 
blacksmith's shop in the neighborhood, from which he had lately 
been forbidden by his mother. In order to punish him for his 
disobedience, she took him in her arms, and set him down in a 
chair with some violence. He was immediately seized with 
choking and with a violent cough. As soon as he could answer, 
he said that it was caused by a nail in his mouth. 

The cough for a time subsided, but shortly returned with some 
attendant inflammatory symptoms of the lungs, which lasted a 
week. At the end of that period, as the child was lying over 
a chair, with its head hanging downwards, a sudden clucking 



FOREIGN BODIES IN THE AIR-PASSAGES . 101 

noise was heard, as if a substance had been thrown up into tlic 
windpipe, and was at once followed by a paroxysm of suffoca- 
tion which nearly destroyed him. He was placed in a sitting 
posture, and the obstruction was shortly removed. 

He had twice had similar attacks, always coming on when the 
head was in a dependent position. In the intervals, he had a 
hoarse cough, and also had night-sweats, loss of appetite, and 
emaciation. 

In this state I saw him. He was rapidly failing from the 
irritation of the luno-s. 

The signs, on auscultation, were as follows : The whole chest 
was flatter than natural on percussion. On both sides a loud 
mucus rale was heard, rather more marked on the left than on 
the right side, but not sufficient to determine with precision in 
what part of the -lungs the substance was imbedded. 

In the course of six days, he had four attacks of suffocation 
from the dislodgement of the foreign body, which rose into the 
trachea. The last attack came on while he was at "dinner, 
and so suddenly that he fell back as if he had been shot, and 
was with great difficulty recovered. 

Being now fully satisfied of the presence of a foreign sub- 
stance in the air-passages, I determined to perform the operation 
of tracheotomy, and directed his father to be sent for. This 
was on Friday ; and the time appointed for the operation was 
the ensuing Monday, as the earliest date at which the father 
could reach the city. 

The following course had been marked out : — 

The child being firmly bound to a board, to make an opening 
into the tracheaj just above the sternum, with the hope that, in 
consequence of the irritation thus produced, the foreign sub- 
stance would be forced up, and present itself at the orifice of the 
wound. If this did not happen, to invert the body, which, in all 
probability, would cause its dislodgement, and thus it might 
pass through the epiglottis, the violence of the spasm of that 
organ having subsided; or, at any rate, it might be extracted 
through the wound. 

The preparations having been made, on the day appointed for 
the operation, ten drops of laudanum were given in divided 



102 THE NECK. 

doses, in order to produce as much quiet as possible during 
the dissection of the neck and opening of the windpipe. Pre- 
vious to its performance, I proceeded to make a last examination 
of the chest, and, much to my surprise, found that the mucous 
rale had almost entirely disappeared. His mother said, also, 
that the cough had been much less for the last two days, and 
there had been no recurrence of suffocation since the violent at- 
tack of Friday. Under these circumstances, it was decided to 
invert the body before opening the windpipe. This was most 
thoroughly tried, and the fauces repeatedly irritated by passing 
a quill down the throat, but without eifect. The operation, of 
course, was not persisted in ; and, in fact, from this time he be- 
gan to improve in health, and fully recovered. 

I heard from him some months afterwards. He was in good 
health. 

Remarhs. — The apparent mystery connected with this case 
seems to be explained in the following manner : — 

To questions as to circumstances attendant on the last par- 
oxysm of suifocation, tlie mother said, that, while he lay on the 
floor, as she thought dead, she seized with her fingers the tough 
and stringy mucus protruding from his mouth, and, when pull- 
ing on it, it seemed to unwind from a body in the throat ; 
— that on Saturday and Sunday, the two following days, the 
child suffered from severe j^ains in the bowels, which were re- 
lieved at night by a powerful faecal discharge, forty-eight hours 
after the attack of suffocation. It is highly probable, therefore, 
that the nail, rolled up in the tough, adhesive mucus, was 
thrown up into the larynx, completely obstructing its passage ; 
and that the mother, by pulling on the mucus, partially detached 
it from the nail, and finally dragged the latter into the throat, 
whence it was swallowed, and ultimately discharged in the 
evacuations. 

Case LXIY . — A Bit of Birch Baric in Left Bronchus. 
Qirl^ aged Eight Years. Laryngotomy on the Sixteenth 
Bay. Yain Attempts at Extraction. Death at the End of 
a Month and a Half after the Accident. Injianmiation 
of the Left Lung and Pleura. — Nov. ^^^ 1850, a girl eight 



FOREIGN BODIES IN THE AIR-PASSAGES. 103 

years old, while chewing a bit of birch bark, let it slip into the 
windpipe. The accident was instantly followed by a paroxysm 
of couo'hino' and suffocation, which continued to recur at inter- 
vals for nearly a week. A sudden change in tlie position of the 
substance, on the 1st of December, was succeeded by a return of 
such violent coughing and strangulation as to excite fears in re- 
gard to the immediate result. At the end of the paroxysm, the 
bark settled down into one of the bronchial tubes, with a miti- 
gation of the severe symptoms. I saw the child Dec. 9th, when 
the breathing was much oppressed, and she had a constant dry 
cough. She looked haggard, and the countenance had a livid 
hue ; the skin was hot and dry ; the pulse one hundred, and the 
appetite lost. The left side of the chest was duller, on percus- 
sion, than the right ; and scarcely a respiratory murmur could be 
detected in the posterior part of the corresponding lung : there 
were mucous rales on a level with the bifurcation of the trachea. 
In front, especially above, the breathing was still performed, 
though very feebly. On the right side, the respiration was 
puerile. All these circumstances denoted that the substance was 
lodofed in the left bronchial tube. 

The following night, she had another paroxysm of coughing, 
during which the bark was again dislodged, and passed up 
into the larynx. The attack was attended with slight epistaxis. 

Laryngotomy was performed Dec. 12th, the patient being fully 
etherized. A pair of forceps, six inches in length, and so con- 
structed as to open only an inch at the end, was then carried 
down into the left bronchial tube, but without grasping the 
offending substance. The operation was thrice repeated ; the 
instrument being retained each time about one minute, without, 
apparently, the slightest inconvenience. She was next suspended 
by the heels, and the throat irritated to provoke free vomiting, 
but without avail. Finally, the abdomen was compressed, and 
the air in the lungs suddenly and violently expelled by the hands, 
applied to the chest. The child, considerably exhausted, w^as 
put to bed, and the opening protected by a bit of gauze. She 
had a quiet night, with less cough ; and the wound manifested a 
disposition to close. 

After several weeks, she was taken home. The conaestion of 



104 THE NECK. 

the lungs increased; and she expired Jan. 9, 1851, nearly a 
month after the operation, and nearly a month and a half after 
the accident. 

The right lung was in a healthy state. The left lung was 
dark-colored, pitted on pressure, was firmly attached to the dia- 
phragm, and excessively loaded with blood and serum. The 
bronchial tubes were filled with muco -purulent matter, and 
those on the left side were in a state of high inflammation. 
The offending body, three-quarters of an inch long and one 
quarter of an inch wide, with the appearance of being much 
swollen, was found lying loose in the trachea. It had evidently 
been accidentally pushed up, during the examination, from the 
left bronchial tube, where there were marks of its having been 
impacted. 

Case LXV. — Bit of JSTut in Left Bronchus. Girl^ aged 
Four Years. Laryngotomy. Ejection of the Shin and Ker- 
nel of a J^ut, folloived by a small Bit of the Shell at the end 
of a few iveelcs. Recovery. — In April, 1851, I was called to 
see, in consultation, a child who, four days before, had inhaled a 
bit of nut. She was seized with violent coughing, paroxysms of 
which had continued to recur at intervals. At the time of my 
visit, her countenance was livid, breathing diflicult, and her 
strength much impaired. Auscultation revealed a great dimi- 
nution of the respiratory murmur in the left lung, with some 
rales ; while, on the right side, it was distinctly puerile. 

As the symptoms were urgent, the crico-thyroid membrane 
was immediately divided, while the child was under the influence 
of ether. A bougie, slightly bent, being passed into the left 
bronchial tube, the substance was readily dislodged, and the 
skin and kernel of a nut were expelled at the artificial opening. 
After further search, under the supposition that part of the 
oflending body might still remain, the operation was concluded, 
and the child put to bed. 

On the following day, the patient was doing well, and ap- 
peared greatly relieved. The wound healed rapidly, and she 
was soon able to go about. Some cough, however, remained, 
accompanied with a mucous rale in the left lung. 



rOEEIGX BODIES IN THE AIR-PASSAGES. 105 

At the end of a few weeks, the child suddenly brought up, in 
a paroxysm of coughing, a small bit of nut-shell. All the 
symptoms now disappeared, and she rapidly regained her 
health. 

Case LXYI. — Pin in Larynx. Ejection into Throat 
during Operation. Death, thirty-six hours afterwards, from 
Exhaustion. — I was requested by Dr. Patch, about the mid- 
dle of the day, to see a child, who, he said, was in a state of 
suffocation from a pin in the windpipe ; and whom, it was pos- 
sible, we should not find alive. He had been called to it in 
the morning, at nine o'clock, when the accident had first oc- 
curred ; but, the substance having settled down into the lungs, 
and relief beino- obtained, and the doubt existino: as usual in 
regard to the facts of the case, he left it for further observation. 
The symptoms having recurred, I was called in. The child 
was then quite black in the fiice, partially insensible, and the 
foreign body flying up and down in the trachea. 

Tracheotomy was at once performed, the dissection being 
much embarrassed from the distension of the fat and short neck 
with venous blood. As soon as the trachea was opened, the 
spasm of the larynx subsided, and the foreign body seemed 
to disappear. An instrument was passed up into the mouth, 
and down to the bifurcation of the trachea ; but no trace of 
it could be detected. When the blood had passed into the 
larynx, causing, as it always does, a severe paroxysm of cough- 
ing, the pin had evidently been driven up into the mouth, and 
swallowed. 

The child now slowly revived from the state of asphyxia ; the 
breathing became free and tranquil ; and, during the remain- 
der of the day, and the following day, there was no return 
of cough. He continued, however, pale, and without good re- 
action ; dying on the night of the second day, apparently from 
the shock received by the accident, as we occasionally see in 
patients recovered from drowning. 

Case LXVH. — A Grain of Corn in the Trachea, 
Oj}eration. Extraction of the Substance. liecovery. — In 

14 



106 THE NECK. 

the spring of 1862, a child of about five years of age was 
brought into the Hospital by its mother, who said that, two days 
before, it had got a grain of corn into the windpipe. The strug- 
gle for life was, for a time, violent. Eesort was had to the usual 
means of relief; and respiration finally became quiet, leaving 
him much exhausted. Since then, he had been hoarse and 
stuffed, but without any return of strangulation. A subcrepi- 
tant rale was heard over the whole surface of the lungs, on both 
sides ; but rather greater over the left than the right lung. 
There was also greater absence of respiratory sound on the left 
side. 

On account of the danger of waiting, it was determined to 
try the following experiment : — 

The child, being etherized, was suspended with the head down- 
wards, as in a former case, and sharply struck on the back, the 
fauces being at the same time irritated ; but these efforts were 
without effect in dislodging the foreign substance. The child 
was therefore retained in the house, and narrowly watched. 

On the next day, the respiration was easier ; and he appeared 
generally in a better condition, although it was very difficult to 
make an investigation, on account of his excessive timidity, 
which, in children, is often a most serious obstacle to diagnosis. 
On the next day, the house-pupil reported that the night had been 
quiet ; but, on visiting him later, the mother informed me that 
he had since had an almost fatal attack of suffocation. In the 
course of this attack, the child had brought up a good deal of 
thick mucus, which she had dragged out from its mouth with 
her fingers. I decided at once to operate. 

The child was etherized, and the trachea opened. On the 
entrance of air and blood, the usual convulsive action resulted, 
followed by the appearance of the kernel of corn at the aper- 
ture, and its almost immediate expulsion. All the symptoms 
were at once relieved ; and the child went home well, ten days 
after the operation. 

If the operation had been delayed, the result would, in all 
probability, have been fatal. 

Conclusions. — The following conclusions may be deduced 
from a review of these and similar recorded cases : — 



FOREIGN BODIES IN THE AIR-PASSAGES. 107 

In the first place, it is unsafe to trust to the chance of spon- 
taneous expulsion any substance which is liable to have an 
increase of bulk from the heat and moisture of the human 
body ; as, in all probability, the swelling will render its exit 
impossible. 

2d, Metallic substances, or those not embraced under the pre- 
ceding head, when engaged in the larynx or lodged in the 
lungs, may be trusted with more impunity. If flat, they natu- 
rally present an edge to the tube, so as to permit the passage 
of air on either side. When lodged in the bronchus, such a 
substance becomes, after a time, enveloped in mucus, so as to 
obstruct the free act of respiration : it is then forced upwards, 
and, in the struggle which ensues, the mucus is disengaged. 
The body then falls back, and remains quiescent until it again 
becomes covered with mucus, when the process of dislodgement 
is repeated. Sometimes, in the violent cough which occurs at the 
change of place, it is forced out into the mouth, and swallowed 
or ejected; at others, by coming up suddenly, when the pa- 
tient's attention is distracted, it takes the larynx by surprise, as 
it were, and easily escapes. 

An interesting case of this latter class occurred in a little 
girl, a patient of Dr. Hale, on whom tracheotomy was per- 
formed, by Dr. J. C. AYarren, for the removal of the wooden 
stopper of an inkstand, which had been sucked into the trachea. 
As soon as this passage was opened, all irritation subsided ; 
the foreign substance settled down into the bronchus ; and al- 
though the wound was kept open a week, and attempts made to 
dislodge it, they were without avail. Some months afterwards, 
as the patient was looking out of a window, very intently 
watching the passing of a military company, the stopper came 
up, without effort, icto the mouth, and was at once expelled. 

3d, If the substance is fixed in the bronchus, and the patient 
young, the prospect of seizing it by instruments introduced 
through the wound, and carried down in the direction of the 
lungs, is extremely small. In fact, I do not know of a single 
successful case upon record, with the exception of one in which 
Mr. Liston opened the trachea of an adult, and, introducing the 
forceps with some difiiculty, seized a bone, which had become 
engaged in the right bronchus. 



108 THE NECK. 

4th, Some doubts will arise, however, as to the propriety of 
leaving, in any case, a foreign substance, for a period of time, in 
the lungs, without an effort to remove it. For although it may 
finally become detached and be ejected, as it frequently is, after 
remaining many months or years imbedded in the lungs, or 
stowed away in the bronchial tubes, yet fatal organic lesions are 
not uncommonly the result. The surgeon must therefore be 
guided by the particular circumstances of each case. 

It is remarkable in how great a number of these cases, which 
we find recorded as having occurred in children, the substance 
introduced was a common garden bean. 



CROUP. 

Tracheotomy is also required in many cases of croup. About 
twenty years ago, I operated several times in such cases. Im- 
mediate relief from suffocation was obtained, and, for a few 
days, the result seemed almost miraculous ; but the lungs had 
become affected, and the powers of life so weakened that the 
final result was fatal. An earlier performance of the operation 
was necessary ; but, at tliat time, the public, and even the pro- 
fession, were not convinced that there was little or no danger 
attending it. I have never seen a case where death could be 
ascribed to it. Tracheotomy in croup was revived in Boston by 
Dr. George H. Gay ; and the practice has been followed suc- 
cessfully by Drs. Samuel Cabot, Henry G. Clark, and many 
other surgeons in Boston and elsewhere. 

After the operation, the air of the room should be kept warm 
and moist. A double tube should be used, and competent per- 
sons employed to watch the patient, and remove the inner tube 
in case of obstruction. I have no doubt that many lives have 
been lost for want of this precaution. The tube suddenly be- 
coming obstructed by thick, adhesive mucus, the patient is 
seized with violent symptoms, and the alarmed parents send for 
medical aid ; but the physician arrives only in time to see the 
case terminate. Many of the deaths which formerly took place 
after the earlier operations for croup undoubtedly arose from 
the want of the inner tube. 



CROUP. TEACHEOTOMY. 109 

The following cases are illustrative of tracheotomy, as re- 
quired in some other affections : — 

Case LXYIII. — Laryngitis. Tracheotomy. — A woman 
about 30 years of age came into the Hospital, in April, 1859, 
under the care of Dr. J. B. S. Jackson. She had been suf- 
fering for some days apparently with a severe cold on the lungs, 
and much hoarseness ; but no alarming symptoms appeared till 
about the time of Dr Jackson's morning visit. He had just left 
the bedside and crossed the ward, wdien the nurse called to him 
that the patient was suffocating. Upon stepping back, he 
found her with her face purple, great difficulty of breathing, 
entire loss of voice, pulse quick and fluctuating, the body 
bathed with cold sweat. 

Seeino' the danoer imminent, he immediatelv sent for me, 
making preparations himself to do the operation in case I was 
not to be found. I received the messao-e as I was enterino* 
the Hospital, and proceeded at once to its performance. AYhen 
the first incisions were made, the blood rushed out of the vessels, 
both arteries and veins, of a color nearly as black as ink. As 
soon as the trachea was opened and the tube introduced, after 
the first violent efforts which usually accompany this proceeding* 
had subsided, she began to breathe regularly and freely. It was 
five or ten minutes, however, after the free entrance of air, 
before the blood assumed its natural vermilion color. 

She was very carefully watched ; and the internal tube re- 
moved and cleansed whenever the mucus became dry, and ob- 
structed its canal. 

She did remarkably well ; and, at the end of a week, the 
tube was removed. She recovered her voice, and was im- 
proving very rapidly, when she arose in the night, and walked 
into a cold room with bare feet, which produced a slight return 
of her trouble, from which she had a slow convalescence. As 
Dr. Jackson remarked, in this case the patient seemed to be 
literally snatched from the jaws of death. 

Case LXIX. — Tracheotomy. A Case in ivhich the 
Operation was reiieated three times in an Adult. — Dec. 17, 



110 THE NECK. 

1864. JohnMcK., 50 years of age, fisherman. The follow- 
ing is the substance of a letter, narrating the case, from Dr. H. 
E. Davidson, of Gloucester, Massachusetts : — 

Three years ago, contracted a severe cold, accompanied by 
a catarrhal affection, w^lth much obstruction of the nostrils. 
This was followed by necrosis of the bones of the palate, from 
which exfoliation afterwards took place. The following winter, 
hoarseness and impairment of voice came on, which continued 
to increase until June, when obstruction of breathing occurred, 
requiring the performance of tracheotomy, which was done 
July 22, 1863. This afforded entire relief. For three weeks 
after the operation, frequent applications of strong solution 
of nitrate of silver were made to the larynx ; after which the 
canula was removed, as the breathing had become quite free 
through the natural passage. 

On the second day of October following, the patient was 
seized with violent dyspnosa, threatening speedy suffocation. 
Tracheotomy was again performed, affording instantaneous re- 
lief. 

The nitrate of silver was again used as before ; and, in 
November, 1863, he was taken to the Massachusetts General 
Hospital, where he was submitted to laryngoscopic examination, 
but without detecting any other difficulty than inflammation of 
the epiglottis. The continued use of the nitrate of silver was 
advised, toofether with the internal administration of the iodide 

' CI 

of mercury, in small doses. Jan. 1, 1864, the breathing had 
become so free that the tube was again removed. 

In August, 1864, while engaged in fishing off the coast of 
Maine, the obstruction returned ; rendering it necessary for him 
to hasten home for relief by a third operation, which was per- 
formed Aug. 10, 1864. Since that date, he has not been able 
to do without the tube. 

This patient was a large, powerful man, and, with the excep- 
tion of the present difficulty, perfectly healthy. In speaking, 
he generally inserted a small cork in the orifice of the canula, 
which enabled him to articulate in a low, hoarse voice. Any 
attempt at labor, however, produced great difficulty of breath- 
ino- ; and it was for this reason that he applied to me for advice. 



CROUP. TRACHEOT03IY. Ill 

The question was, why the passage of air through the larynx 
was not as free as it had been after former operations. The 
tube, he said, did not cause him the slightest uneasiness. 

The man was placed in a strong sunlight, and the tube 
removed, when it was found that granulations had shot into the 
fenestrum, in the upper side of the canula, and had partially 
obstructed it ; the aperture being, evidently, too near the outer 
end of the tube. The whole tube was now withdrawn, when a 
fit of coughing ensued, followed by the projection into the aper- 
ture of two or three polypoid bodies, which were hanging down 
into the trachea from the lower edge of the w^ound. These were 
successively seized, as they were forced out during paroxysms of 
coughing, and removed. Another tube was now introduced, hav- 
ing the fenestrum on its upper side, at a greater distance from the 
shield ; so that the aperture was wholly included in the larynx. 
He at once breathed more freely, and spoke with a clearer voice. 
A few days after, this tube was replaced by another, made with- 
out the fenestrum, when he breathed equally well, the air pass- 
ing on the outside of it. It seemed probable that the wound 
had been irritated by contact with the sharp edges of the 
opening in the tube, not only causing a crop of granulations 
to shoot into it, but producing also a thickening of the parietes 
of the trachea, from the polypoid growths already referred to. 

The shape of the present tracheotomy tubes is generally de- 
fective, the tube being set too obliquely on the shield ; the fact 
being forgotten, that it has to enter first nearly horizontally, and 
then vertically. As originally made, they were thus angular in 
form; the present curved figure having been adopted later, 
in order to admit of the introduction of the inner canula. Of 
the importance of this inner movable tube, it may be instanced, 
that, in the present case, it had to be removed three times a day, 
in order to clean away the dried accumulations which obstruct 
its canal. 

Dr. H. K. Oliver, at my request, made an investigation of 
the state of the larynx, with the laryngoscope, with the fol- 
lowing result : In a good light, tlie whole interior of the larynx 
could be most distinctly seen. The vocal cords were both much 
thickened, and partially disabled in action, the cord on one side 



112 THE NECK. 

overlapping its fellow. The arytenoid cartilages were also dis- 
torted, and much impeded in their motions. The rima glottidis 
was extremely narrow. 



FOREIGN BODIES IN THE (ESOPHAGUS. 

Case LXX. — A Cent arrested in the (Esophagus. Ex- 
traction. — A child two and a half years old was brought to 
me on Feb. 16, 1859, who, four days before, had swallowed 
one of the large old-fashioned cents ; and had not since been 
able to take any solid food, and, in fact, almost refused to 
swallow any thing. The child was firmly held in a sitting 
posture, its head carried back by an assistant, and a piece 
of wood placed between the teeth. The finger of the right 
hand was now carried down the throat, and an attempt made 
to discover the situation of the foreign body. The spasm 
about the throat and glottis was very great, the struggles of the 
child were violent, and the respiration almost stopped by the 
exploration. After several attempts, during which the first 
joint of my forefinger was severely bitten, a trace of a metallic 
substance was discovered, which might, however, have been one 
of the cartilages of the larynx. I decided to make no further 
attempts that day ; but to resume them on the next, under the 
influence of ether. 

On the following day, being provided with sufficient assist- 
ance, and the patient being well etherized, the forefinger of 
the left hand was passed down the throat, while the teeth were 
separated by a bit of cork ; and, after one or two efibrts, by 
pressing the larynx forward, the foreign substance could be just 
touched by the end of the nail. This effort it was very soon 
necessary to discontinue, as it impeded the respiration. A long 
curved polypus forceps, very flat and smooth, was now selected ; 
the forefinger of the left hand was carried down as before ; and 
the larynx being protected, so that the instrument should not 
pass into it, the forceps Avas introduced laterally, and, after one 
or two attempts, the very edge of the coin seized, and at once 
extracted. 

The difficulty in this case arose from the depth at which 



FOREIGN BODIES IN THE (ESOPHAGUS. 113 

the foreign body had lodged, making it ahiiost impossible to 
seize it without injury to the important neighboring parts, during 
the violent perturbation caused by the introduction of the fin- 
ger and instrument into the vicinity of the larynx. To a person 
who is going to attempt this operation, I would advise a slneld 
prepared of gutta percha, fitted over the first joint of the fore- 
finger, to protect it from the teeth of the patient : as I have 
often suffered for many days after from contusions received 
during similar operations, notwithstanding the ordinary gags, 
and other means to prevent the closing of the teeth. 

It is alwaj's very important, when a foreign body is lodged 
in the neighborhood of the larynx, that the forefinger of the 
left hand should serve as a guide to the instrument, to prevent 
it from doing injury to the very important organs in close prox- 
imity. Otherwise the epiglottis, the edge of the larynx, or the 
neighboring soft parts, may be seized and lacerated. When 
the foreign body is lodged fiirther down the esophagus, this is 
unnecessary, as the probang or hook of Dupuytren, having 
once passed by the larynx, may be manoeuvred low down in the 
oesophagus without much danger. It is, however, proper to 
say, that foreign bodies very seldom lodge in this location ; for, 
if they once become disengaged from behind the box of the 
larynx, they generally pass easily into the stomach, and do no 
farther injury. 

I have generally observed, that, where cents have been swal- 
lowed, they have made their appearance about the third day 
afterwards. In one case, one was retained about three weeks, and 
then passed without injury to the patient. I mention this fact, 
as parents are, in general, exceedingly anxious when a copper 
coin remains in the intestines of a child. 

Case LXXI. — A Cent in the GEsophagus. Extraction. 
— A child five years of age was brought to me, July 25, 1849, 
who had been partially choked by a cent, which had lodged in 
the oesophagus. Attempts had been made to disengage it, 
which only served to force it farther down. 

In order to reach it, I forced the forefino^er of the left hand 
down the throat ; and, with much effort, was able to touch it 

15 



114 THE NECK. 

with tlie end of the nail, as it lay just below the larynx. After 
one or two attempts, a pair of forceps, opening anteriorly and 
posteriorly, and curved on the flat side, were slipped over it, 
guided by the finger, and the cent seized and extracted. 

These cases will serve to show the position of metallic sub- 
stances in the oesophagus, which sometimes remain there for 
a long time without causing fatal consequences. I removed a 
quarter of a dollar from a child five or six years of age, which 
had remained for one or two weeks behind the larynx, without 
preventing the passage of solid food. Bones, for the most part, 
are lodged higher up, and require a different management. 
The finger, however, should always be used as a guide. 
Within a week of writing this, I removed, from the throat of a 
gentleman, a large fish-bone firmly wedged across the opening 
of the larynx. 

STEICTURE OF THE (ESOPHAGUS. 

Strictures of the oesophagus require a very delicate treatment. 
On the one hand, if arising from traumatic causes, and of a 
fibrous character, they are susceptible of great relief; and the 
patient suffering from starvation may be restored to a state of 
almost perfect health by a persevering and judicious application 
of dilating instruments. On the other hand, if the affection is 
malignant, the use of instruments is sometimes extremely per- 
nicious. 

There is reason to believe, that a stricture of a non-malignant 
character, after a duration of many years, may, from the de- 
terioration of health, or from other reasons, take on a malignant 
course. It is difficult to decide whether the affection is can- 
cerous. The complexion of patients suffering under stricture 
often assumes a pale yellow appearance, which would, at first, 
lead to the supposition that there was constitutional disease. 
By judicious treatment, particularly by the use of malt liquors, 
where solid food cannot be swallowed, a change for the better is 
very soon manifest. Where the disease is cancerous, the use of 
instruments increases the soreness, and they are often withdrawn 
covered with blood. For dilatation, the best instrument is a rod 



STRICTURE OF THE (ESOPHAGUS. 115 

of whalebone, with a piece of ivory on its end, of a conical rather 
than of a globular shape. Where the stricture is quite small, 
and pouched at its side, I have had most success by using a 
conical wax bougie, with the tip. bent forward; and this will 
often succeed in passing the stricture, when the straight one 
would be caught in the sac. I know of a number of patients 
now living and in health, for whom I dilated strictures many 
years ago, who previously had not swallowed solid food for 
months, and in some cases for years. 

The following cases, selected from a great number, are given 
to illustrate the treatment : — 

Case LXXII. — Stricture of (Esophagus from Caustic 
Ammonia. — In September, 1862, a young woman, 19 years 
of age, married, and nursing a child, came to me in a state of 
almost complete starvation, at that time having swallowed 
nothing for the previous tAvelve hours. She said that, about 
two years before, when ill, she swallowed, by accident, a tea- 
spoonful of caustic ammonia, instead of her proper medicine. 
A violent inflammation of the oesophagus ensued, and she had 
not been able to swallow solid food since. She had lived prin- 
cipally on milk, and animal broths ; but, the system being de- 
pressed from nursing, irritation had come on at the strictured 
part, so that she could swallow nothing. I made an attempt 
to pass the smallest-sized probang of whalebone, the ball on its 
end being about the size of a pea ; but it was arrested about 
half-way down the oesophagus, and would not go farther. I ad- 
vised her to wean the child, and live for a few days on nutritive 
enemas. This she did, and was then again able to swallow 
liquids. On the 11th of October, she was etherized. After a 
number of efforts, I finally succeeded in passing through the 
stricture, into the stomach, a small gum-elastic catheter, with 
a stylet in it, bent to give it a curve forwards. This operation 
was afterwards repeated from time to time, without the use of 
ether; and I saw her last in 1865, in good health, enabled to 
swallow semi-solid food, but still occasionally requiring the use 
of an instrument. 



116 THE NECK. 

Case LXXIII. — Stricture of the (Esophagus occurring 
after Ohohing. — A lady, 35 years of age, consulted me in 
December, 1861, for a stricture of the oesophagus of thhleen 
years' standing, produced, as she supposed, from gettmg choked 
while swallowing a piece of beefsteak, which produced a severe 
spasm, and was finally ejected with some blood. Three years 
before this, a lozenge had stuck in her throat, and remained 
there until it had dissolved. Since the last accident, she had 
with difficulty swallowed any solid food. In fact, she had been 
gradually reduced to the necessity of using only liquid nourish- 
ment. 

On the 3d of December, I passed a probang having a bulb 
the size of a pea. It went through a stricture, a little below the 
larynx, with some difficulty, bringing a little blood with it. She 
was ordered a nutritious diet, with porter. Her aspect, at this 
time, was that of a person with a malignant disease. A little 
soreness, which lasted two days, followed the operation. On the 
third day, tlie same instrument was again passed, with similar 
effi3Ct. The size of the instrument was gradually increased, 
and she was soon able to take solid nutriment. The use of the 
instrument was continued, at longer intervals, for a year, the 
power of taking solid food increasing. She now (1866) no 
longer requires treatment, and enjoys a moderate degree of 
health. 



TU3IORS IN (ESOPHAGUS. 

Case LXXIV. — Polypus of Pharynx of Large Size at- 
tached to the outside of Epiglottis. Operation. Cure. — 
This case is interesting as being almost unique, on account of 
the size and situation of the tumor. 

The patient was a gentleman, 54 years of age, who began, 
in 1860, to have a soreness of the throat in swallowing. About 
ten weeks afterwards, by a voluntary effort, a tumor could be 
forced up into the mouth, from the oesophagus. This did not 
give him much inconvenience till about three weeks since, when 
it began to increase rapidly, causing much trouble in deglu- 
tition. 



TUMORS IN (ESOPHAGUS. 



117 




He applied to me May 
1, 1866; and I could 
hardly credit the state- 
ment he made with re- 
gard to the size of the 
tumor. By making, how- 
ever, a regurgitating ef- 
fort, he at once con- 
vinced me of the fact. 
A large, white-looking 
tumor, of the shape and 
size of a small sausage, 
was thrown up into the 
mouth. While in this 
position, it caused con- 
stant efforts to vomit. 
(^See woodcut.) 

Seizing it with forceps, I passed my finger down the throat, 
and found that the tumor orio^inated in the neiohborhood of the 
epiglottis. By a slight effort of the patient, it resumed its 
situation in the oesophagus. 

Being examined by Dr. H. K. Oliver, with the laryngoscope, 
its origin was found to be by a broad base, commencing low 
down on the left and outside of the epiglottis, which it dragged 
down and over to the same side : thence a ribbon-like pedicle 
extended into the oesophagus. On the 2d of May, it was removed 
in the following manner : — 

Being brought up into the mouth, it was transfixed by means 
of a curved needle armed with a long thread so as to control 
it. It seemed quite vascular, and bled freely. Instead, there- 
fore, of excising it, I passed a strong ligature down the throat, 
and tied it as near the base as possible. The tumor was then 
cut off in front, witli Simpson's long curved scissors. 

The portion removed was about three inches long and two 
inches in circumference, and of a fibrous character. 

Considering the position of the ligature, in the neigborhood 
of the larynx, the symptoms which followed were of a mild 
character. There was no constitutional disturbance, and the 



118 



THE NECK. 




patient swallowed liquids 
without much difficulty. 
On the third day, a la- 
ryngoscopic examination 
showed the ary-epiglotti- 
dean ligament, on the left 
side, in an cedematous state. 
The ligatures, the loop of 
which was secured on the 
outside around the ear, Avere 
concealed by this swelling. 
After being gently drawn 
on for two or three days, 
they came away spontane- 
ously, May 6th, bringing 
with them the pedicle of 
the tumor. The patient ex- 
pressed himself greatly re- 
lieved, as was natural, from 
the operation, and liad no farther symptoms. 

A tumor of so large a size, in this situation, must be uncom- 
monly rare ; and the only case which I have been able to find 
approaching it, though of a different anatomical structure, 
is to be found in Mr. Gibbs's valuable work on the " Throat 
and Windpipe," which I take the liberty to transcribe, its at- 
tachments being nearly the same as in the present one. 



" One of the most remarkable on record is preserved in the mu- 
seum of the Westminster Hospital, of a pendulous, fatty tumor of 
the pharynx and larynx, occurring in a robust and active man, cet. 
80, who had throat-symptoms for twelve years, and four years be- 
fore death, during the act of vomiting, a large mass protruded, which 
he was obliged to return as speedily as possible, to prevent immediate 
suffocation. He died suddenly, while smoking his pipe. A large, 
pendulous, fatty tumor was found filling the pharynx, and extending 
downwards into the oesophagus to the extent of nine inches. It was 
attached by an envelope of mucous membrane and fibrous tissue to 
the left side of the epiglottis, dragging it downwards and to the left 
side, so as entirely to prevent perfect closure of the larynx : it was 



REMOVAL OF TOXSILS. 119 

also connected with the upper part of the pharynx ; but, with these 
exceptions, it hung perfectly loose in the pharynx and oesophagus. 

" The tumor was exhibited before the Pathological Society, by my 
colleague, Mr. Holt ; and is figured in the fifth volume of their 
'Transactions.' " 

The woodcuts accompanying the present case were drawn by 
Dr. Oliver, and represent, 1st, the tumor as seen in the mouth; 
and, 2d, the supposed position of the tumor. A, in the oesopha- 
gus. The base of the tongue, the epiglottis, the larynx, and 
trachea are represented in their integrity, while the remaining 
parts are in section. The epiglottis, B, is drawn down, and to 
the left, by the tumor. C stands upon the greater cornu of the 
left thyroid cartilage, broken down to expose the parts beneath. 

REMOYAL OF TONSILS. 

I know no minor operation in surgery that affords greater 
relief and more satisfactory results than this one. I have per- 
formed it from five hundred to one thousand times, and have 
never lost a single patient, nor had a single case of dangerous 
hemorrhage ; and in but two cases have I seen any such acci- 
dent : both did well. The cases were not taken indiscriminately ; 
nor w^as the operation performed save where the symptoms 
were more or less urgent, and other remedies had failed in af- 
fording relief. Many of these patients were brought from a 
distance, on account of the importance and severity of the 
disease. 

In almost every instance, the symptoms were at once relieved : 
the patient was able to take his food with comfort ; to sleep 
better ; and exchanged a pallid and depressed aspect for a 
healthy and animated appearance, gaining rapidly in flesh as 
soon as a proper amount of oxygen was allowed to penetrate to 
the lungs. 

In four or five instances only have I been obliged to repeat 
the operation. The whole of the tonsil never is, nor ought to 
be, removed. When the enlargement is very great and irregu- 
lar, it sometimes extends down the throat, w^ith a broad base, 
and it is not possible to embrace at once in the instrument as 



120 THE NECK. 

much of the gknd as it would be desh-able to remove, and 
the apex only is excised. The consequence is, that the lower 
portion afterwards rises up, and comes into ^dew, causing ob- 
struction, and requiring another operation. These cases were, 
however, very exceptional. 

Once I saw death occur from enlarg-ement of the tonsils. An 
account of the case is given below. 

In the "Philadelphia Medical Examiner," 1846, I published 
an account of certain deformities of the chest, attended with an 
enlargement of the tonsils. 

The substance of the paper Is contained in the following 
remarks : — 

In 1827, M. Dupuytren published a paper on the lateral de- 
pression of the parletes of the chest, consisting of a depression 
more or less great of the ribs on each side, and a proportionate 
protrusion of the sternum in front, accompanied by some 
antero-posterior curvature of the vertebral column. 

In 1827, shortly after the publication of this paper, Mr. 
Coalson, of London, published some cases in confirmation of 
those given by Dupuytren ; adding, also, three cases of his own, 
of a deformity of the chest, different from that before described, 
the sternum being concave anteriorly, the sides of the chest 
very prominent, and the spinal column but slightly, if in any 
degree, altered from its natural shape. 

In the three cases appended to the paper of Mr. Coalson, 
and three of the four cases of M. Dupuytren, enlargement of 
the tonsils existed ; but In none of them does it appear that 
removal of these organs was practised : so that we can not 
judge what the effect would have been on the symptoms referred 
to the chest, had this operation been done. 

So far as my own experience goes, this condition of the chest 
is partly mechanical, partly constitutional ; being, in a great 
measure, caused, in delicate subjects, by the difficulty of res- 
piration, from the obstruction in the throat, improving imme- 
diately when this is removed. 

The operation, as performed by the present improved instru- 
ment, is instantaneous, not attended with much pain ; in no 
case is there any considerable hemorrhage ; usually, nothing 



REMOVAL OF TONSILS. 121 

more than a few moutlifuls of blood are discharged. The 
patients are able to return home, and resume their ordinary 
occupations, as if nothing uncommon had occurred; only a 
slight soreness being experienced for a few days. 

The following cases illustrate the symptoms of this disease : — 

Case LXXY. — Enlargement of Tonsils in a Child of 
Five Years, with Otorrhea. Excision, with Relief . — W., 
of Newton, Mass., five years of age, November, 1836. For 
two years, this child suffered from an enlargement of the 
tonsils, first manifested by a swelling which appeared on the out- 
side of the throat, and supposed to be mumps. As the disease 
increased, he gradually lost flesh and strength, and was subject 
to frequent sore throat, attended by febrile attacks, occurring as 
often as once a fortnight, and lasting two or three days. He 
breathed at night with great difficulty, and occasionally started 
up, as if from choking, when the sleep became profound. One 
ear was inflamed, and there was a purulent discharge from it : 
he was very sensitive to any loud musical sound. He was 
small of his age, thin, and of an irritable disposition. The 
chest was found to be much deformed, presenting that appear- 
ance called excavated sternum : it being very much depressed 
in its centre; and the ribs, at the union of the cartilages, ele- 
vated, so as to form with them an acute angle. 

The tonsils were so much enlarged as to touch each other, 
and entirely obstruct the posterior part of the fauces. One of 
the tonsils was removed, and afforded immediate relief to all the 
symptoms. In the month of April following, some difficulty 
being experienced in breathing, the other was also excised. I 
saw him Aug. 3, 1837, nearly a year after the first operation. 
From being a miserable child, whom, as his mother stated, 
she had not the least idea of raising, he had become a fine, 
healthy boy ; had been perfectly free from difficulty of respira- 
tion, and had had no febrile attack since tlie operation. The 
sensitiveness of the ear had diminished, and the deformity of 
the chest was much less obvious. 

IG 



122 THE NECK. 

Case LXXYI. — Enlargement of Tonsils in a Boy of 
JEighteen Years, tvith Deafness. Excision, with Restora- 
tion of Hearing. — B., aged 18, November, 1836. For two 
or three years, had been subject to frequent attacks of sore 
throat; for three months, had had a purulent discharge from 
the right ear ; was quite deaf in both ears. He apphed for 
advice on account of the deafness. 

On examination of the ears by the speculum, the tympanum, 
of each side, was found to be in a perfectly sound state. On 
the side from which the discharge appeared, the lining mem- 
brane of the ear was reddened, and covered with a purulent 
deposit. The tonsils Avere found to be very much enlarged, 
and there was considerable redness of the back part of the 
fauces. 

Astringent remedies being tried for a fortnight, without ef- 
fect, both tonsils w^ere removed. On the following day, he 
began to hear better : on the second day, his hearing was per- 
fectly restored, and sounds even became so acute as to be 
painful. 

In a day or two, the deafness returned, and lasted a week : 
he then recovered his hearing, and has remained perfectly well 
since. I saw him more than two years after, and he had expe- 
rienced no return of his difficulty. 

To these cases might be added one or two in which these 
organs were removed while the patient was laboring under an 
attack of severe tonsillitis. In one case, the symptoms were 
immediately removed by the operation ; in another, inflammation 
had extended to the adjacent parts, and an abscess formed, as is 
often seen in this disease. The affection, however, was much 
shortened in duration, lasting four days instead of fourteen, as 
had been usual with this patient, who was liable to attacks 
every winter. The operation was repeated ; and the other ton- 
sil was removed, on a subsequent attack, with the same result. 

The instrument used in these operations has usually been the 
guillotine instrument, as described by Dr. J. C. Warren in his 
work on tumors. It is without any steel movable neeedle, used to 
fix the tonsil and prevent it from falling into the throat, which 
appears to be useless, as the blade of tlie instrument drives the 



REMOVAL OF TONSILS. 123 



lining membrane of the tonsil into its groove, and thus secures 
it; and, even if this were not the case, the mucus, which covers 
the fauces, causes the excised part to adhere to the blade, so 
that there is no danger of its escaping into the throat. 

From a review of a large number of cases, I find that many 
of the children were of a scrofulous constitution ; that the en- 
largement of the tonsils caused great local trouble, attended 
wdth considerable constitutional disturbance ; that the patient 
was much more liable to inflammatory attacks of the throat, 
than in cases where this condition does not exist ; and that 
they were less liable, after the operation, to these attacks. 

In about half of all the cases, and in about two-thirds of 
those of children, deformity of the chest existed. Whether 
this depended on the general constitutional habit of the patient, 
or was induced by the obstruction in the throat to the free 
passage of air, the accounts received as to the exact time wdien 
either affection was first observed, were not sufficiently accurate 
to justify a decision. It is certain, however, that this deformity 
does not increase, but rather diminishes, after the removal of the 
obstruction in the throat. The operation is a simple one, at- 
tended with no danger, and almost always affords immediate 
relief to the symptoms. 

Case LXXYII. — Strangulation from Enlarged Tonsils. 
— A man was brought into the Hospital, struggling for breath, 
and almost pulseless, supposed to be laboring under an attack 
of larvnij-itis. The dano-er of suffocation was so imminent that 



124 THE NECK. 

no time could be spared to inquire into the history of the case. 
I ordered him to be placed on his back, and proceeded to open 
the larynx, — a matter of some difficulty, owing to his violent 
effiDrts for breath. As soon as the air penetrated freely into the 
larynx, he began to revive ; the pulse became more steady, 
the respiration regular. Stimulants were given both by the 
mouth and per anum ; but the system had received too severe a 
shock to recover, and he gradually sank, and expired quietly 
in an hour or two after the operation. On removing the 
larynx, no marks of inflammation could be detected. On 
looking further, however, the cause of death was discovered. 
The tonsils, greatly enlarged, and in a state of violent inflam- 
mation, filled up the posterior fauces. The epiglottis had been 
gradually encroached upon, so that finally it was pressed 
down, and almost completely prevented the entrance of air 
into the lungs. The history of the case, as learned after- 
wards from his father, was this. He had been employed, four 
days before, in unloading a ship ; the weather being very cold 
and rainy. The following day, he was taken with sore throat, 
for which some simple remedies had been applied on board the 
vessel where he slept. He was first seen by a physician on 
the day he was brought to the Hospital. 

Cancer of Tonsils. — Cancer of the tonsils, soft palate, 
and uvula, is exceedingly rare. Dr. Walshe, in his work on 
the " Nature and Treatment of Cancer," says that cancer of the 
tonsils is very rare, whether of the scirrhous or encephaloid 
variety. He has not seen a case of primary cancer of the soft 
palate and uvula, nor found any recorded. "In certain cases," 
he adds, " where the pharynx and soft palate are implicated, it is 
perfectly possible that the aflection may have originated in the 
palate, or that this part may, at least, have been the seat of 
separate formation ; but I know of no evidence of the fact.'' 
The following case, which I attended with Dr. J. C. Warren, 
is one of the very few which I have seen. This one is selected 
on account of the remarkable transposition of the organs, which 
was not discovered until after death : — 



EEMOVAL OF TONSILS. 125 

Case LXXYIII. — Cancer in the Throat. Operation 
and Recovery. Deaths at a Subsequent Period^ from Pe- 
ritoneal Inflammation. Remarhahle Transposition of all 
the Organs. — Mrs. A., aged 65, somewhat dyspeptic, ob- 
served, in January, 1835, a swelling on the left tonsil, which 
gradually increased in size ; became more firm in consistence ; 
and, finally, extended to the soft palate, and attached itself to 
the lower jaw so as materially to impede its motions. She was 
not much reduced in strength by the disease, not much emaci- 
ated : her countenance was pale, and her digestion good. The 
following was the state of the diseased parts just before the 
operation : — 

On the left side of the throat, and occupying all the back 
part of the fauces, was a firm, indurated tumor, extending back- 
wards and upwards into the posterior nares, and forwards to 
the lower jaw, to which it was firmly attached. The tonsils of 
that side and soft palate were also implicated. There was no 
doubt of the cancerous nature of the disease. The tumor 
was removed in June. It was of a firm, cartilaginous nature, 
almost of a bony hardness, somewhat ulcerated in the centre. 

She recovered, though, from her age and the severity of the 
operation, it was some months before she was able to go about. 
In the month of January, 1836, having exposed herself to cold, 
she was seized with violent peritoneal inflammation, and died 
after an illness of four days. The examination of the body 
was made by Dr. George C. Shattuck and myself, the day 
after her death. 

On opening the abdomen, the ordinary appearances presented 
by a severe peritoneal inflammation were found. The most 
remarkable thing, however, was a tumor in the left iliac region, 
at first supposed to be an invagination of the intestine, but 
which, on further examination, proved to be the ccecum; and, in 
tracing up the intestine to the stomach, this organ was found 
in the right hypochondriac region, the left being occupied by the 
liver. 

The heart lay to the right of tlie spinal column, occupyiiii^ a 
place with the right lung, which consisted of but two lobes, 
there being three of the left lung : the cavities were all, in like 



126 THE NECK. 

manner, transposed. From the right auricle proceeded the 
four puhnonary veins : the right ventricle had the form and 
thickness usually possessed by the left, and contained the mi- 
tral valves. The left auricle received the vena cava, the left 
ventricle contained the tricuspid valves. From the right ven- 
tricle, the aorta had its origin ; this, after running up a little to 
the left, curved over to the right, and was placed on the right 
side of the spinal column, having the vena cava on its left. 

From the arch of the aorta, only two arteries, instead of 
three, were given off, forming another peculiarity in this re- 
markable case. The first artery to the left was the largest in 
size; an inch from its origin, divided into what would cor- 
respond to the innominata and right carotid. The innominata 
gave off the left carotid and subclavian : the other artery given 
off from the arch was the right subclavian. The specimen is 
now in my possession. 

The subject of this remarkable anatomical structure was the 
mother of fifteen children. Nothinsr was observed durino^ life 
to lead one to suppose that such a disposition of organs existed. 



FISSURE OF SOFT AND HARD PALATE. 

The operation of staphyloraphy is of comparatively modern 
invention. It was first attempted in Europe by Graefe (1817), 
and was first performed with success by Roux (1819), who 
seems not to have known of the unsuccessful attempt of the 
German professor. Shortly after, it was again performed by Dr. 
John C. Warren, of Boston, who, not being aware of what had 
been done in Europe, himself invented new instruments for it. 
The operation was at first deemed applicable only to fissures of 
the soft palate, which, of course, are almost the exceptional 
cases ; as, out of from eighty to one hundred operations for 
fissure of the palate which have fallen under my own observation, 
in not more than a tenth, probably, of the whole number, was 
the fissure limited to the soft parts. Nearly all cases of fissure 
extending into the hard palate were rejected as unfit for opera- 
tion, althouoh Roux had susfo^ested the idea of relaxinn^ the soft 
palate by cutting it completely away from its attachments at 



riSSUEE OF SOFT AND HAKD PALATE. 127 

the posterior edge of the palate bones. This operation is very 
likely to prove abortive, from the division of the vessels which 
supply the flaps with nourishment; and, even if it succeeds, it 
leaves an imnecessarily large aperture in the bones, still to be 
covered by artificial means. Being impressed l)y the very great 
proportion of the cases of cleft palate which were deemed in- 
curable, I was led to perform an operation for the especial 
relief of the more extensive fissures, which include both the 
soft and hard palate ; and, in April, 1843, I published, in the 
" New-England Quarterly Journal of Medicine and Surgery," 
an account of a new operation for the closure of fissures in the 
hard palate, together with a very important modification of 
the operation of staphyloraphy, as practised for the relief of fis- 
sures of the soft palate. The operation upon the hard palate 
(I quote from the description of my first case as reported at 
that time) consisted in "dissecting up, with a long, double- 
edged knife, curved on its flat side, the membrane covering the 
hard palate, pursuing the dissection quite back to the root of 
the. alveolar processes. By this procedure, which was not ef- 
fected without considerable difiSculty, the membrane seemed 
gradually to unfold itself, and could be easily drawn across 
the very wide fissure. A narrow slip was now removed from the 
edges of the soft palate, and with it the two halves of the uvula. 
By this means, a continuous flap was obtained, beginning at 
the roots of the [incisor] teeth, and extending backwards to the 
edge of the velum palati. Finally, six sutures were introduced, 
on tying which the whole fissure was obliterated. . . . This 
patient returned home into the country at the end of three 
weeks ; a firm, fleshy palate being formed behind, and half the 
fissure in the bony palate obliterated. In the following spring, 
I again operated on the remaining fissure in the hard palate, and 
succeeded in closing half the extent of it ; the tissues yielding 
with some difliculty, owing to the induration caused by the 
former operation. The small aperture which remained, I di- 
rected to be closed by a gold plate." I had, at this time, opera- 
ted in this manner in fourteen diflerent cases, " which, with one 
exception, had terminated successfully, either in the closure of 
the whole fissure of both hard and soft palate, or so far that the 



128 THE NECK. 

aperture which remained in the bones could be easily closed by 
an obturator fitted to the adjoining teeth." 

The improvement to which I have alluded, in the operation 
upon the soft palate, consisted in the relaxation of the tissues 
of the fissured velum, by means of incisions, made with strong 
curved scissors, so as to divide the attachments of the soft 
palate to the tonsil and to the posterior pillar ; or, in other 
words, dividing the posterior pillar of the palate just where it 
begins to spread out into the velum. The efiect of this in- 
cision is at once seen in the almost complete relaxation of the 
parts, so as to admit of their easy approximation and union by 
suture. At this tune, I had met with no case in which this 
procedure failed to relax the parts, as I thought, sufficiently for 
the requirements of the operation ; and, in the fourteen cases of 
operation for complicated cleft palate which I had then per- 
formed, I had met with but one unsuccessful result. In subse- 
quent operations, however, I found that there existed, in some 
cases, an additional obstacle to the approximation of the flaps, 
which could be overcome as easily, and in the same manner, as 
the former. This obstacle consists of a band of firm tissue, ex- 
tending above and behind the soft palate, and standing out in 
bold relief when that organ is put on the stretch by drawing 
upon it with the forceps. This resisting mass, like the other, 
I have always divided by an additional stroke or two with the 
scissors, whenever the incision of the posterior pillar and ad- 
jacent mucous membrane has seemed insufficient properly to 
relax the palate. By this division of all the parts which oppose 
any active resistance to the approximation of the sides of the 
fissure, the operation, as I have performed it, was finally per- 
fected in its essential features ; and, since that time, I have 
known of no important improvements in it, except in a few 
matters of operative detail. During the past few years, how- 
ever, I have generally abstained from the attempt to efiect the 
entire closure of very extensive fissures in the hard palate, 
owing, in part, to the severity of the operation, but chiefly 
to the fact, that modern improvements in mechanical dentistry 
have furnished us with a most efficient and comfortable substi- 
tute for the natural hard palate, in the form of a metallic or 
hard rubber plate* 



FISSURE OF SOFT A^^D HARD PALATE. 129 

By the introduction of these improvements in the plan and 
methods of operating, the sm'gery of cleft palate at once ac- 
quired a new and vastly enlarged importance. The operation 
of staphyloraphy, as invented by Roux, and practised by many 
surgeons, both in Europe and America, had been considered 
applicable only to simple fissures of the velum, a class of cases 
constituting but a very small fraction of the total number of 
cleft palates, and the very ones in which the need of surgical 
aid is least urgent. 

The highly successful results, however, which I was enabled 
to report in the treatment of cases which had previously been 
considered as beyond the aid of surgery, together with the en- 
couraging success which had been already attained by Roux, 
DieiFenbach, and many other surgeons, from the operation in 
the soft palate, soon excited the renewed interest of the pro- 
fession in this most distressing deformity. 

Mr., now Sir William, Fergusson, was led, in 1844, by the 
dissection of a specimen of cleft palate, to adopt a method very 
similar to mine ; dividing the levatores palati muscles, with a 
slender curved knife, somewhat higher than in my procedure 
with the scissors, and dividing the posterior pillars of the 
palate in precisely the same manner as I had already de- 
scribed. 

The subject of cleft palate has been still further illustrated by 
several British surgeons of distinction ; among whom Messrs. 
Avery and Pollock of London, Mr. Collis of Dublin, and 
Mr. Field of Brighton, are especially prominent. All these 
gentlemen have operated v\nth the most perfect success upon 
fissures as well of the hard as of the soft palate, and they 
have all adopted the plan of separating tlie soft textures freely 
from the palatine arch. ISlv. Pollock divides the palate mus- 
cles by a partially submucous incision, at a point near the 
hamular processes, where the fibres begin to spread out into the 
velum. 

The following account of the different stages of the operation , 
as I have lately performed it, very nearly resembles that which 
I published in 1843, to which allusion has been made : — 

17 



130 THE NECK. 

1. The Separation of the Palatine Membranes from the 
Bones. — This procedure I have found necessary in fully nine- 
tenths of the cases upon which it has been my lot to operate. 
In most of the fissures which apparently extend only to the mar- 
gin of the bony vault, the top of the fissure is of a rounded 
rather than an angular form, so as to render it difficult or im- 
possible to bring the flaps together at this part without first 
loosening their attachments. By adopting this measure, how- 
ever, the upper sutures are applied as easily as the lower ones ; 
and the danger of partial failure at this particular part of the 
palate, formerly so common, is almost wholly obviated. In 
cases of more extensive fissure of the hard palate, this separa- 
tion is to be carried further, in some instances even to the alveo- 
lar processes. I have always completed the operation, as far 
as I have thought it proper to attempt it at all, at a single sit- 
ting, because in this way we are almost certain to obtain good 
union of the velum, and a partial closure, ^9«r glissement, of 
at least the posterior portion of the fissure in the bones. When- 
ever, by the re-establishment of the velum and of the posterior 
part of the palatine vault, we have succeeded in reducing the 
fissure to a simple foramen in the hard roof of the mouth, we 
have practically relieved the patient from his disgusting and 
distressing deformity ; for he only needs a light metallic or vul- 
canite plate, such as is now worn by every one who has a set of 
false teeth, to enable him to articulate as well as if the aperture 
were closed by the natural bone and membranes. Led by these 
considerations, and by the desire to shorten as much as possible 
an operation which must almost necessarily be performed with- 
out the aid of anaesthesia, I have ceased, of late years, to 
operate for the closure of the anterior portion of the cleft in 
extreme cases ; and this notwithstanding the fact, that, in my 
earlier years of practice, I succeeded in completely closing a 
very large proportion of all the fissures upon which I operated, 
includino- some very extensive ones, and thus established the 
operation as a perfectly practicable one. In commencing this 
part of the operation, I have always used a knife substantially 
like that which I first employed; viz., a double-edged, spear- 
pointed knife, strongly curved on its flat side; which I have 



FISSURE OF SOFT AND HARD PALATE. 131 

found- to answer well for almost all fissiu'es of moderate extent, 
although in some extreme cases, in w^hich the bones have de- 
viated widely from their normal curvature, very considerable 
difficulty has been experienced in making the first incisions at 
the edges of the fissure. In these cases, there is often no pro- 
per roof to the mouth, owing to the extreme obliquity of the 
bones, which rise, as it were, almost vertically from the alveolar 
margins towards the nostrils. To facilitate these first incisions 
in such cases, it has been proposed by Dr. Smyly to commence 
the dissection with a slender knife, shaped somewhat like an 
ordinary gum-lancet, and used through the nostril, where the 
edge of the fissure may be more readily reached than from 
the mouth. Sharply recurved knives, worked from the mouth, 
have also been used for the same class of cases ; and a particu- 
larly ingenious one has been invented by Mr. Pollock, in which 
a short chisel-shaped blade is attached to a metallic stem by 
means of a hinge, and is fitted with a screw movement by which 
it may be adjusted to any required angle. Both these contri- 
vances have been tried and approved by Mr. Collis, and are 
doubtless of great utility in the cases for which they are de- 
signed. This commencement of the dissection at the edges of 
the fissure is by far the most difficult part of the operation ; for 
it is at this part of the palate that the membranes are always 
found most firmly adherent to the bones. As we proceed, how- 
ever, the separation becomes very much easier, and the mem- 
branes seem almost to peel off from the bones, I have therefore, 
at this point, generally abandoned the knife, and have continued 
the dissection, as far as I have thought necessary towards the 
alveolar processes, by means of curved scissors. In this way, 
I have been sure of preserving the greatest possible thickness of 
tissues in the flaps, without endangering their nutrition by the 
division of the palatine arteries. In most of the cases which I 
have seen, there has been little or no deficiency of materials to 
fill the gap ; but the fissure has been the result rather of the 
oblique direction of the ununited sides of the palatine vault. 
The operation consists, then, not so much in stretching the flaps 
tightly across the cleft, as in bringing them into a more nearly 
horizontal position. I have not, therefore, seen that much 



132 THE NECK. 

benefit is to be expected from lateral Incisions through the pala- 
tine membranes, and have always abstained from making them, 
from the fear of causing needless and troublesome hemorrhage, 
and thus unnecessarily prolonging an already too tedious opera- 
tion. At the posterior edges of the ossa palati, the union 
between the soft parts and the bone is very intimate, owing to 
the insertion there of the tendinous fibres of the velum, and 
more particularly of the reflected tendons of the tensores palati 
muscles. For completing the separation at this point, I use a 
pair of probe-pointed scissors, which I have found to divide the 
firm tissues much more conveniently and expeditiously than any 
knife. In all the operations which I have performed, I have 
met with but a sins^le case of troublesome hemorrhao-e. At the 
moment of freeing the flaps from their attachments to the pos- 
terior margins of the palate bones, a few arterial twigs are 
generally divided ; but I have always been able to control the 
bleeding by the use of iced water. In a single instance, how- 
ever, in which the upper stitch was unusually tense, the bleeding 
continued after the adjustment of the sutures, but immediately 
ceased when the stitch was divided so as to allow the membrane 
to apply itself more closely to the bone. 

2. The Relaxation of the ttvo Halves of the Yelum hy the 
Division of Resisting Rands of JSTuscle and Mucous Mem- 
brane. — This has been a most important feature in all the 
operations, and Is still performed In the same manner as in 
the earliest cases. The instrument employed is a pair of large 
and strong French scissors, curved on the flat side. One of the 
halves of the split uvula is seized with appropriate forceps, and 
drawn across the fissure. This brings out in bold relief two 
strongly resisting bands, one below and one above the palate. 
The former, consisting of the posterior pillar of the palate, is 
then divided by a powerful stroke of the scissors, and the in- 
cision extended forwards and backwards, dividing as much of 
the mucous membrane as may be necessary to relieve all tension 
at this part. The other band, consisting chiefly, as Sir William 
Fergusson has shown, of the levator palati muscle, with Its 
mucous coverings, is next divided in the same manner as the 
posterior pillar, including, as before, in the incisions, a greater 



FISSURE OF SOFT AND HARD PALATE. 133 

or less extent of the adjacent mucous membrane, as may seem 
to be requisite to effect the perfect relaxation of the organ. 
The completion of this stage of the operation is shown by 
the striking change in the condition of the half of the velum, 
which, from a state of violent spasmodic contraction, burying 
itself, as it were, in the side of the throat, becomes perfectly 
flaccid and powerless. As soon as this result is attained, this 
part of the operation is to be considered as finished, whether the 
incisions have been more or less extensive. By this method, no 
part is divided until it has been first brought into a state of 
tension, and thus shown to require it. For facility and certainty 
of execution, dividing no more and no less than is required, and 
for absolute freedom from danger, it seems to me that this 
method of relaxing the soft parts has never been surpassed. 
That other plans may be useful, I have no doubt ; but whether 
they offer advantages equal to the present can be settled only 
by a series of comparative trials in practice, such as have not yet 
been made. 

3. The Paring of the Edges of the Fissure. — This is per- 
formed sometimes with scissors, and sometimes Avith a slender, 
pointed knife ; and I am not aware that there is any decided 
preference to be given to either method. The edge of the flap 
is made tense by drawing upon the uvula with a pair of strong 
but slender-toothed forceps, vrhich I have devised for the purpose, 
and which is shown in the plate. These forceps, of which two 
pairs are required for the two sides, are made with a double 
curve, and are so contrived as to seize the extreme edge of the 
palate without encroaching more upon one surface than the other. 
The same forceps are employed also in the preceding stage of 
the operation to put the palate on the stretch ; and, as a general 
rule, after once seizing the organ, I do not let it go again until 
I have pared its edge. I have not found it desirable to attempt 
to preserve the wliole uvula ; for it generally hangs so low in the 
throat as to cause irritation, and thus interfere with the success 
of the operation. In most cases, therefore, I remove the greater 
portion of the two halves of this appendage at the time of paring 
the edges of the palate. 

4. The Application and Adjustment of the Sutures. — In 



134 THE NECK. 

the early days of staphyloraphy, this was by far the most diffi- 
cult and vexatious part of the operation, owing to the extreme 
irritability of the parts provoking violent muscular retraction 
whenever the flaps were pricked by the needle. After adopting 
the plan described for the relaxation of the organ, I observed 
that this stage of the operation was greatly facilitated ; so 
that, for a number of years, I was in the habit of passing the 
sutures with a small curved needle held by forceps. Increased 
experience has, however, demonstrated the usefulness, in many 
cases, of the ingenious crochet-aiguille of Schwerdt; a sharply 
recurved needle, mounted in a handle, and having an eye at its 
point which can be opened and closed by a slight pressure upon 
a spring. The instrument is threaded, and passed through the 
edge of one of the flaps from behind forwards, and one end of 
the thread drawn through by catching the loop with a tenaculum 
or hook. The needle, still threaded, is then withdrawn, and 
carried through the flap on the opposite side ; the eye is then 
opened, and the thread wholly disengaged from it by drawing 
upon the loop. I have generally adjusted the middle suture 
first, by that means controlling the palate, and thus rendering 
the insertion of the others easier. The lower one is best insert- 
ed last. At the lower part of the palate, where the parts are 
very movable, I have found it difficult to fix them with this 
instrument, and therefore prefer to use a delicate curved needle 
held in a porte-aiguille. The chief objection to the needle of 
Schwerdt is the difficulty of keeping it sharp, owing to its being 
split at the point. Very broad sutures, made of a number of 
waxed threads arranged in the form of a flat band or tape, have 
been much employed in France ; and Dieflenbach used to insist 
strongly upon the advantage of using wires of soft lead. I 
have always used a single thread of common surgeon's silk, 
thoroughly waxed, and tied with the ordinary surgeon's knot. 
I have prepared the silk, at the suggestion of Dr. C. G. Page, 
by soaking it, a day or two beforehand, in the compound tinc- 
ture of benzoin, by which it acquires an adhesive property, and 
is less apt to slip when the knots are tied. It is important 
to bring the opposite edges of the fissure into absolute contact 
with each other without much tension, or the stitches will 



FISSUEE OF SOFT AND HARD PALATE. 135 

as certainly cut their way out, and thus defeat the end for 
which they are employed. In an interesting case of operation 
for the closure of a very extensive fissure of the hard palate, 
performed by Mr. Collis, and reported in the " Dublin Quar- 
terly Journal of Medical Science" for February, 1865, the 
flaps, although of ample breadth, tended obstinately to revert 
to their original position in contact with the bones, and thus 
caused injurious tension upon the stitches. This was overcome 
by the very happy and ingenious expedient of pushing the 
flaps, as it were, towards the median line, by means of 
wedges of sponge introduced between them and the bones : 
these were easily removed through the nostril, after forty-eight 
hours, and the result was a nearly complete and most satisfac- 
tory union. 

5. The After-treatment. — This was formerly the severest 
and most vexatious part of the management of the case, owing 
to the supposed necessity of the interdiction of the use of food for 
several days following the operation. In my first cases, I pur- 
sued this plan, nourishing the patients for several days solely by 
enemata. The obviously unfavorable effect of thus starving a 
person in full health, and accustomed to a generous diet, led Sir 
Philip Crampton, of Dublin, to try the experiment of allowing 
his patients an ample supply of soft food, such as boiled bread 
and milk, custard, soup, jelly, &c., during the whole period of 
the treatment. The publication, in January, 1843, of the two 
cases in which this plan had been successfully tried, was im- 
mediately followed by the abandonment of the old and most 
irksome restriction ; and patients are now allowed as much 
liquid or semi-solid food as they desire. Much trouble is 
often experienced, after the first three or four days, from 
the secretion of toui2:h adhesive mucus in and around the 
line of suture, which oives rise to an irritatinof couo:h of 
such severity as sometimes to threaten the destruction of the 
newly formed adhesions. In this condition of the parts, I 
have seen much benefit from the use of warm or acid drinks, 
or from brushing the parts with a weak solution of nitrate of 
silver. 

At first I was disposed to remove the sutures at the earliest 



136 THE NECK. 

possible period ; but latterly, from having once had all the 
adhesions give way during the act of withdrawing the threads, 
I have allowed them to remain a very long time. It is rather 
important that the mouth should not be too widely opened 
during the early stages of the adhesive process. Once, on the 
fifth or sixth day, I have known the entire wound to give way, 
from the patient opening the mouth too widely for the purpose 
of inspection. 

The number of cases of cleft palate upon which I have oper- 
ated by these methods is now about a hundred : of this number, 
in less than one-tenth was the fissure confined wholly to the 
soft parts ; and, in at least three-fourths, the gap extended into 
or through the maxillary portion of the palatine vault. In not 
more than nine or ten cases, therefore, have I found it practi- 
cable to close the fissure, witliout first dissecting up the mem- 
branes from the posterior part of the hard palate, and cutting 
throuo'h the tendinous attachments of the velum to the ossa 
palati. I have in no case been deterred from operating by the 
extent of the deformity ; and, in several cases of most formidable 
aspect, I have succeeded in improving the voice and facilitating 
deglutition, as completely as in even the simplest fissures of the 
velum. In one case of simple fissure of the soft palate, I was 
tempted to operate without first dividing the muscles. The 
edges of the fissure came so easily together, that any farther 
incisions seemed unnecessary ; and for several days every thing 
looked fair. About the seventh day, however, the adhesions 
gave way, owing, as I believe, in part at least, to the imperfect 
method adopted. As to the proper age at which to operate, 
in one case of a fissure which extended but little more than 
through the uvula, I operated on a child of between six and 
and seven years ; but generally it is necessary to wait until the 
patient is old enough to fully appreciate the importance of the 
operation, and to submit patiently to pain and inconvenience : 
for this is one of the very few operations in which the use of 
anaesthetics is inadmissible. Under very peculiar circumstances, 
I suppose, ether might be administered, but not without some 
risk to the patient, and much embarrassment to the surgeon, 
from the constant flow of blood down the throat. 



FISSURE OF SOFT AXD HARD PALATE. 137 

The result of these operations may be stated briefly as fol- 
lows : With the exception of perhaps half a dozen cases, I 
have never failed to get more or less union of tlie soft palate. 
Sometimes one, or more rarely two, of the sutures have given 
way at the upper part, where the tissues are put most fully on 
the stretch. If any of the stitches hold, however, and the 
smallest union takes place, it may be afterwards extended either 
by the renewal of the sutures, which is now a com])aratively 
easy matter, or by the occasional application of the solid nitrate 
of silver to the angle of the remaining fissure. The great point 
is to establish the arch of the soft palate as completely as pos- 
sible ; and, when this is once accomplished, any aperture which 
may remain in the hard palate can be effectually closed by 
simple mechanical means. In cases of extreme fissure extending 
through the alveolar arch, where a few artificial teeth are almost 
always required to fill the gap caused by the lost or distorted 
incisors, the plate upon which the new teeth are mounted serves 
also to close the remaining cleft in the roof of the mouth. Of 
course, in all cases, the more completely the fissure can be 
closed by the operation, the better it is ; but what I wish particu- 
larly to enforce is the fiict, that, even in the extreme cases of 
very wide fissure in the bones, an operation can be performed 
which is as effectual in restoring the voice, and almost as easy 
of execution, as in cases confined to the velum or extreme back 
part of the palatine vault. 

The question is often asked of the surgeon whether the voice 
will be immediately restored by the operation ; and, if not, in 
what time the full restoration may be expected. The answer 
must, of course, be very indefinite ; for, in fiict, the patient has 
now to learn, for the first time, the art of using the palate in 
articulation. Almost every patient, after the opening is entirely 
closed, experiences a sense of relief, which is owing both to the 
greater ease with which deglutition is performed, and also to the 
protection afforded by the new palate to the mucous membrane 
of the posterior fauces, which, before the operation, was dry and 
parched from the constant passage of the air over it. I have 
lately had occasion to see several patients two or three years after 
the operation. Two of them are teache/s in public institutions ; 

18 



138 THE NECK. 

and the only defect to be perceived is a slight huskiness of the 
voice, which would hardly be noticed by any one ignorant of 
their former condition. I do not remember to have seen a case 
in which the patient was not materially benefited. 

These remarks are condensed principally from a report made 
to the American Association in 1865, and borne out by farther 
experience. It is thought unnecessary to introduce cases in 
illustration, which is done in that paper, farther than one or two 
which are remarkable for some peculiarity. 

Case LXXIX. — Congenital Fissure of the Soft and 
Hard Palate^ tvith Double Harelip. — Patient 20 years of 
age. By an operation performed on the lip, six years before, 
the intermaxillary bone had been almost wholly removed : as is 
usual after this operation, the maxillary bones had been dragged 
into contact with each other in front. The palatine processes 
of the maxillary and palatine bones seemed almost wanting, and 
the whole arch was very narrow. Operation : From the ex- 
treme deficiency of the bonj^ vault, the membranes could not be 
made to come together across the gap. The velum, however, 
united. After a fortnight, finding that the coverings of the hard 
palate had become very much thickened, I again dissected them 
up, and this time was able to unite the flaps by suture. lie- 
sult : Partial closure of the gap left after the first operation, 
with a thickened, fleshy state of its edges, which seemed to 
promise a still further diminution in its size, or possibly even its 
entire obliteration. The remaining hole, which was quite 
small, was closed by two bits of elastic vulcanized India-rubber, 
stitched together in the form of a shirt-stud. A plastic opera- 
tion was afterwards performed upon the lip and nose, with the 
effect of very greatly improving the appearance of the patient. 

Case LXXX. — Fissure of the Hard and Soft Palate, 
with Median Fissure of the Alveolar Arch, and Double 
Harelip. — The patient was a young man, 17 years of age, 
upon whom a very dexterous and perfect operation for double 
harelip had been performed in infancy, by my friend Professor 
Willard Parker, of New York. At that time, as Professor Par- 



FISSURE OF SOFT AND HARD PALATE. 139 

ker has kindly informed me, he removed, from the extremity of 
the vomer, a small osseous tubercle, which formed a projection 
similar to that often caused by the intermaxillary bones in cases 
of double harelip complicated with double fissure of the alveolar 
arch. I had been consulted, from time to time, on account of 
the cleft in the palate ; but it was not until he had attained the 
age of seventeen years that he finally came to me for an opera- 
tion. This was performed in the manner already described 
at length, w4th the result of perfectly re-establishing the velum, 
and covering the posterior portion of the cleft in the bones. 
The operation w^as more difficult than usual, owing to the 
small size of the mouth, resulting from the previous opera- 
tion on the lip, and the unusual obliquity of the two ununited 
halves of the palatine vault ; yet the improvement in articulation 
w^as more speedy and more decided than I remember ever to 
have observed in any other case. A very few weeks after the 
operation, he was able to wear a gold plate, which was made for 
him by Dr. Rufus E. Dixon, of this city ; and it w^as at this 
time that my attention was particularly attracted to the alveolar 
arch and the anterior portion of the fissure. The upper lip was 
so closely applied to the teeth in front as wholly to conceal them, 
except when lifted with the fingers. A glance at this part of 
the mouth revealed a remarkable deviation from the ordinary 
condition of the jaw in this deformity, inasmuch as it showed the 
existence of a perfectly symmetrical median fissure extending 
completely through the alveolar arch, betw^een the central in- 
cisor teeth. Upon the right side of the cleft w^ere seen the first 
and second permanent incisors ; then the canine tooth, out of 
line, and placed rather above and in front of its normal position ; 
then the two bicuspids ; and, lastly, the two molars. In front of 
and above the right lateral incisor was the corresponding milk- 
tooth, hanging quite loose in the gum. Precisely the same 
number of teeth existed on the left side of the cleft, even to the 
presence of the lateral incisor of the temporary set. The cen- 
tral milk-incisors had also formerly existed, one upon each side 
of the fissure ; but had been removed, a few years before, on ac- 
count of a tendency to cross each other, and press against the 
lip. At my request, Dr. Dixon removed the two remaining 



140 



THE NECK. 




milk-teeth, and also the 
right central incisor of the 
permanent set, which 
seemed disposed to take 
an awkward poitison as re- 
garded both the lip and 
the jaw. A cast of the 
mouth has been preserved 
and figured, showini? the 
position of the fissure and 
the arrangement of the 
-^^-^ teeth. See woodcut. 

The woodcut presents 
the state of the parts in 
the case of median fissure. Being taken from a cast made 
after the operation, it shows the restoration of the posterior 
part of the hard palate, together with the velum : it serves 
also to give a general idea of the extent to which it is aimed 
to close extensive fissures in the bony arch. 

This is, so far as I am aware, the only case ever observed of 
a true median fissure of the alveolar arch, or, in other words, 
the only one in which the cleft has been seen to occupy the 
position of the line of suture which separates the two inter- 
maxillary bones from each other. In all cases hitherto noticed, 
the cleft in the alveolar arch has been upon one or both sides ; 
corresj^onding, in most cases, to the line which marks the union, 
in early foetal life, of the maxillary with the intermaxilhiry 
bones. 



Case LXXXI. — Fissure of Hard and Soft Palate. 
Double Harelij), operated 07i 17 years before. Operation. 
Cure. — The following case is interesting, as showing the 
anatomical appearances presented by the palate in a person 19 
years of age, who had been operated on seventeen years before 
for double harelip, with removal of the intermaxillary bone. The 
lip was short and contracted, and presented a large red place in its 
central part, produced by the prolabium, which ran quite up, 
through the whole central region of the lip, to meet the middle 



FISSURE OF SOFT AXD HARD PxVLATE. 141 

portion of skin which covered the intermaxillary bone. This 
had not been worked into the lip as is generally done, but sim- 
ply formed the septum of the nose. The result demonstrated 
this advantage, that no scar was left, as usual, leading to both 
nostrils ; but the cicatrix on the right side was concealed above 
in a plait of skin, that on the left side being alone visible. This 
result was dependent probably upon the fact, that the operation 
had been performed at two separate times upon the two sides of 
the lip. The case suggested the idea, that, if the intermediate 
portion of skin were more fully removed, and only sufficient left 
to form a septum for the nose, the scar afterwards, instead of 
presenting the unsightly form of a letter Y, would have the sim- 
pler form of a single cicatrix in the median line. The appear- 
ance of the bones was as follows : — 

The maxillary bones had not come together, but were sepa- 
rated by an interval of at least an inch. The first teeth upon 
the sides were the canines ; and there were, upon each side of 
the jaw, five teeth above and seven below. The vomer was cen- 
tral over the back part of the fissured palate, which is gen- 
erally the case in simple cleft palate uncomplicated with harelip ; 
but in front it curled to the right side, and seemed to unite with 
the anterior part of the upper jaw. It resembled, to a certain 
extent, a fissure of the palate complicated with harelip on one 
side only, in which case the vomer is generally continuous with 
the palatine plate of one side. What the nature of this ap- 
parent union was, does not exactly appear, when it is remem- 
bered that the intermaxillary bone, which is always attached 
to the end of the vomer, had been removed. It is possible, 
that, from the early age at which the operation had been per- 
formed upon the lip, these parts may have been drawn to- 
gether, and coalesced. 

I operated on this young man in June, 1863, for the fissure 
of the palate ; the operation being perfectly successful. An 
artificial plate, with incisor teeth attached, was afterwards intro- 
duced to fill the gap in the jaw, and cover the remaining fissure 
in the hard palate in front. 

The following observations were made eighteen months after 
this operation, when the patient consulted me medically. As 



142 THE NECK. 

regards the restoration of the voice, it was less than in the 
greater proportion of cases in which I have operated ; for what 
reason I could not exactly determine, as the soft palate was 
quite flexible, was united as low down in the throat, and protec- 
ted the fauces as well, as in the natural state of the organ. 
The improvement, as regarded comfort in breathing and deglu- 
tition , was very great ; as previously he could scarcely take 
liquids without a portion being rejected by the nostrils. 



DESCRIPTION OF PLATE. 



INSTRUMENTS EMPLOYED IN OPERATIONS FOR CLEFT PALATE. 

Figs. 1 and la. Forceps for seizing and holding the edge of the fissured 
velum. They are in pairs, one for each side of the fissure ; Fig. 1 
being for the left side, and Fig. la for the right. 

Fig. 2. Strong French scissors curved on the flat side, shown in profile in 
Fig. 2a; used for dividing the posterior pillar and other resisting 
bands, and for paring the edges of the fissure. 

Fig. 3. Slender spear-pointed knife, which I have sometimes used to pare 
the edges of the fissure. 

Fig. 4. Curved spear-pointed knife, shown in profile in Fig. 4a, which I 
originally employed in separating the membranes from the palatine 
vault. 

Fig. 5. A knife similar to the former, represented also in profile in Fig. 5a, 
but broader and shorter in its curve. This is the knife which I have 
used, for the last ten or fifteen years, in commencing the dissection of 
the covering of the hard palate. 

Fig. 6. Curved scissors, smaller than those shown in Fig. 1, and with points 
nearly sharp ; used in completing the dissection of the membranes from 
the bony palatine vault. Shown in profile in Fig. 6a. 

Fig. 7. Crochet-aiguille of Schwerdt, represented as closed, and with a 
thread in its eye. By pressing upon the lever, the eye is opened, and 
the thread disengaged. 



HAEELIP. 143 



HARELIP. 



It is of much Importance for the future appearance, and even 
for the health, of the child, that this operation should be 
well done, and the proper time selected for it. I have per- 
formed it, with success, as early as seven hours after birth; 
and its early performance was advocated by my grandfather. 
Dr. John Warren. Dr. A. L. Peirson, of Salem, has also pub- 
lished a paper advocating this being done early. On the whole, 
after much experience, I should advise the age of three or four 
months, just previous to teething, and after the tissues have ac- 
quired sufficient firmness, as the best age to select. 

For many years, I have advocated nursing immediately after 
the operation, and while union is going on. By this means, 
the digestive organs are kept in a good condition, and diarrhoea 
avoided, which was often produced by change of diet when feed- 
ing was formerly practised. The muscular action of the lip, 
induced by nursing, rather favors the coaptation than the sepa- 
ration of the edges of the wound, though formerly the contrary 
was supposed. 

I am convinced that sutures are much preferable to needles, 
no matter how wide the separation, and consequently great the 
tension required to bring the parts into contact. They have 
these advantages : first, they are more easily introduced ; second 
they produce less irritation ; and, third, they can generally be 
removed at the expiration of forty-eight, or, at the most, of 
seventy-two hours, without danger of disturbing the tender ad- 
hesions. On the other hand, if needles are used, they must be 
left until they are sufficiently loosened by ulceration, otherwise 
there is great danger of tearing open the wound. The part of 
the lip also embraced by the figure of 8 over the needles is 
often left in an excoriated state. 

When the stitches are used, the intervening parts are exposed, 
so that the process may be watched ; and, by the application of 
a small compress kept constantly wet with water, the inflamma- 
tion liable to occur in very young subjects is so moderated, that, 
on the removal of the sutures, I have frequently found the line 



144 THE NECK. 

of adhesion quite perfect, free from redness, and after a short 
time scarcely to be distinguished. In fact, the tissues seem to 
melt into each other, without any perceptible cicatrix remaining. 

Small, straight suture-needles, held firmly by forceps, will be 
found much more convenient to use than curved ones. 

In regard to the method for avoiding the irregularity which 
so often takes place where the edges of the lip are brought 
together, I should say (having tried the various means that 
have been suggested by cutting the edges of the lip irregularly) , 
that the only sure way is to remove a liberal portion of the 
margin of the fissure beyond the red border just before it begins 
to curve upwards. The union of the parts is much facilitated 
by taking a very fine stitch on the inside of the lip. No dress- 
ings are required until the stitches begin to loosen, then a piece 
of adhesive plaster of a dumb-bell shape is of much assistance in 
maintaining the apposition of the two sides. A¥ith infants, the 
hands should be secured during the treatment, as I have known 
a single blow defeat the whole operation. 

Case LXXXII. — Operation for a Harelip on a Child 
three days old. Icterus. Hemorrhage. Remarkable Closing 
of the Fissure. — The child was a fine one as to size. He 
w^as first seen by me on the day of the operation. During 
the operation, it was observed that there was a yellow tinge 
about the eyes and forehead. This was so slight as not previ- 
ously to have attracted attention. When the incisions were 
made, I remarked to the bystanders that the bleeding was un- 
usually free, the blood being dark-colored, and coming from the 
whole cut surface. The bleeding, however, ceased ; and the 
wound was brought together by sutures. A wet compress was 
applied. Suspecting something wrong, I visited the child an 
hour afterwards. I found the lip swollen, and bleeding quite 
freely. All other means failing to arrest the hemorrhage, it 
was found necessary, in order to save the life of the patient, 
to cut away the stitches, and to include the whole cut edges 
in a series of ligatures. Considerable inflammatory action fol- 
lowed ; but, at the end of a month, the whole wound was entirely 
healed, leaving the fissure, of course, much larger than before 



HARELIP. ^ 145 

it was interfered with. Shortly after this, a contraction of the 
parts took place, commencing at the upper end of the fissm'C, 
and gradually extending downwards so as ultimately to produce 
complete obliteration, no scar being left except on the very edge 
of the lip, which was rather projected downward than hitched 
up, as it often is after the operation of a harelip. The pro- 
cess of closure, in this case, was so remarkable as to demand 
special attention. The occurrence of hemorrhage in connection 
with the symptoms of jaundice is interesting. Dr. Francis 
Minot, in a valuable paper, read to the Boston Society for 
Medical Improvement, has shown that out of thirty-nine cases 
of umbilical hemorrhage, thirty-two had jaundice. It has also 
been shown, that the bleeding from wounds of icteric patients 
is arrested with difficulty. It therefore seems proper to avoid 
operating upon patients in this condition, if possible, until the 
symptoms of jaundice have passed away. 



19 



CHAPTER IV. 
CHEST. 

PARACENTESIS THORACIS. 

The operation for the removal of fluids from the cavity of the 
chest, by puncture, or by the introduction of the trocar and 
canula, has been for a long time employed in the practice of 
surgery. The cases, however, wliich generally fall under the 
hand of the surgeon, are those of chronic disease where collec- 
tions of pus have taken place. In these cases, the simple with- 
drawal of the fluid, followed in some instances with iodine or other 
injections, does not seem to accomplish the object ; and I have 
once or twice made incisions into the chest afterwards, or left 
the canula in place to allow the escape of the fluid as soon as 
formed, before a cure was accomplished. 

The existence of a connection between the bronchial tubes 
and the pleuritic cavity, allowing the escape of air into it, has 
not been an objection ; the aperture in the lung being obliter- 
ated as that organ expanded. 

In tuberculous cases, the relief afforded, in general, is but 
temporary. It is in cases of simple pleurisy, with efl'usion of 
serum or pus into the pleuritic cavity, that the great benefits 
of the operation are observed. In one or two cases where a 
spontaneous or artificial opening has become fistulous, — the 
passage being narrow and devious, — I have seen serious irrita- 
tion set up, giving rise to hemorrhage more or less severe, and 
leading to the supposition that it was caused by a carious condi- 
tion of the rib from the long contact of pus with it, which 
occasionally is the fact. These symptoms have all been relieved 
by making a free incision into the cavity of the chest ; one or 
two cases requiring the removal of a portion of the rib in order 
to keep the aperture freely open, owing to the thickness of the 
pleura from inflammatory action. 



PARACENTESIS THORACIS. 147 

A caution may be given in some old cases in- regard to punc- 
ture when the pleura has become excessively thickened. The 
instrument should be driven in with a certain amount of force 
and decision ; otherwise, the pleura is forced before its point, 
and no fluid is supposed to be present, wdien, in fact, the cavity 
of the thorax has not been entered. 

Of late years, the removal of recent eiFusions of fluid has 
been practised in our vicinity with most successful results by 
Dr. Morrill Wyman, of Cambridge, Dr. H. I. Bowditch, and 
others, by the use of a small canula, with suction applied by 
means of a syringe, so as to prevent the admission of atmos- 
pheric air. 

Case LXXXIII. — Empyema. Fistulous Communication 
with Lungs. Paracentesis Thoracis. Cure. — The patient 
w^as a young man, aged 20, of good constitution, and not of 
a tuberculous family. In March, 1853, he was seized, after 
exposure to cold, with a severe pain in his right side, which 
confined him for six weeks to his house and bed : it was not 
attended with cough or expectoration. After this period, he 
went out, and was able to employ himself partially in his 
ordinary avocations. In June he was suddenly seized, while at 
dinner, with a violent fit of coughing : he left the table, went 
into another room, and expectorated about two quarts of pus. 
From this time his cough and purulent expectoration continued, 
being more severe at intervals of a w^eek, when the chest emptied 
itself of about the same quantity as at first. 

I was requested to see him in the country, in October. He 
w^as then pale and emaciated ; his skin hot, and pulse one hun- 
dred and twenty. His appetite w^as good, and he took the same 
amount of food as in health ; but his system was graduall}^ 
giving w^ay under the disease. He was very desirous of having 
an opening made into his chest, the idea being original with 
him, and not derived from others. 

On examination of the chest, it was observed that the right 
side was enlarged, and that the lower intercostal spaces were 
rather protruded than depressed. There was no decided promi- 
nence or pointing at any particular spot. On percussion, the 



148 CHEST. 

right side was quite flat, except for one or two inches below 
the clavicle, where a subcrepitant rale was noticed. Succussion 
caused a loud, swashing sound, which was heard by the patient 
himself, and had probably brought to his mind the idea of relief 
from a puncture. The respiration on the left side was decidedly 
puerile. 

The chest was punctured with a delicate trocar, about four 
inches from the spine, between the ninth and tenth ribs ; and, 
Guerin's syringe being applied, a pint and a half of thick, 
healthy, inodorous pus was withdrawn. No cough or constitu- 
tional disturbance followed. Great relief in breathing was at 
once perceptible ; and he arose, and walked about the room in 
high spirits. The lung expanded, and respiration could be 
heard along the spine, and for one or two inches below the 
scapula, also much lower down than before In the front part of 
the chest. 

Nov. 4th, this patient was so much better as to be able to make 
a visit to Boston. His cough was now less ; he had gained 
flesh, and his strength was increasing. The respiratory mur- 
mur could be distinguished all along the spine, quite clear, and 
free from crepitus. The side was flat on percussion, and the 
respiration and sounds of heart heard as if at a distance. Nov. 
15th, finding that the pus was again collecting, the chest was 
punctured, and twelve ounces of fluid drawn ofl" with relief. 
As the pus continued to collect, and the symptoms to recur, 
there seemed but little probability of a cure without having 
recourse to a permanent opening. It was therefore decided to 
introduce a large trocar, and leave the canula in the wound. 
To facilitate its introduction, as it was feared the thickened 
pleura and false membranes might resist, an incision was first 
made through the integument, and the trocar then pushed in 
forcibly. What had been feared as a possible occurrence hap- 
pened, — the instrument did not penetrate the cavity of the 
chest, and nothing but a few drops of blood issued. It was 
thought best to delay a repetition of the puncture for a few 
days, and watch the symptoms. A slight irritation took place 
in the wound, and the cough subsided. After a week, he pro- 
posed to return home, and, if necessary, make another visit to 
town, and have the operation repeated. 



PARACENTESIS THORACIS. ' 149 

He was not heard from again until Jan. 9th, 1854, when I 
was called to see him in the country, and found him laboring 
under very alarming symptoms. He was confined to his bed 
in an extreme degree of emaciation ; pulse one hundred and 
fifty, skin clammy. The expectoration was profuse, and so 
offensive as to make it difficult to remain in the same room with 
him. He said that, on his return from Boston, the weather 
being very bleak, he was much exposed, and took a severe cold ; 
from which time the symptoms had all been unfavorable. The 
expectoration was so nauseous as entirely to destroy his appe- 
tite, and the cough was constant and painful. His vital powers 
were so reduced that some hesitation was felt in attempting any 
operation ; but the patient was so urgent that it should be tried, 
and it being the only chance for life, it was resolved upon. The 
fine trocar was used as at first, and two quarts four ounces of 
fetid pus were drawn ofi", with immediate relief. The air passed 
freely in and out of the canula during respiration. He was di- 
rected to keep the aperture in the canula closed with a cork, 
which was to be removed twice daily, and the pus evacuated. 
The patient from this time, under the judicious management 
of his physician, gradually recovered ; and, in May, he was able 
to present liimself in Boston in good health. I saw him in 
November, quite stout and healthy ; and he had no cough nor 
expectoration. He employed himself in his trade of watch- 
making. The lower part of the right side of the chest was flat : 
there was no contraction of that side. Respiration was heard 
below the scapula, without crepitus. I was assisted in the 
above case by the able advice of Dr. Bowditch, and in the last 
operation by Dr. Slade. 

Case LXXXIY. — Pleurisy. Em'pyema, Pus drawn off 
by a Puncture in Back. Afterwards Pointing, and an Open- 
ing made in Front. HemorrJiage, at the end of two years and 
a half ^ from the Anterior Opening. Free Incision. Cure. 
— A gentleman, aged 45, had an attack of pleurisy on the left 
side. Pus formed there, and was drawn off by a puncture in 
the back, with a fine trocar and canula, and great relief afforded. 
Subsequently, there was pointing in the front of the chest; an 



150 CHEST. 

opening was made with a lancet, and the pus evacuated. The 
patient recovered his health ; but a purulent discharge continued 
to flow from the aperture made by the lancet. A few weeks 
before I saw him, a sudden discharge of blood took place from 
this opening, and, recurring once or twice, reduced his strength, 
and incapacitated him for business. At this period, the pus 
escaped through two openings in the integuments by a tortuous 
route. With a probe, the rib, in a carious state, could be de- 
tected. It was thought probable, on consultation, either that 
from the pus being retained in the chest on account of the 
small size or irregularity of the openings, or from the diseased 
rib, a source of irritation existed which gave rise to the hemor- 
rhage. With this idea, it was decided to dilate the external 
openings by means of prepared sponge. This was found to be 
a matter of some difficulty, on account of the great irritability 
of the wound, and could be done but imperfectly ; still the 
patient received a temporary relief from it. The hemorrhage, 
however, was shortly repeated, was more severe than at first, 
accompanied by the appearance of purpura over the whole 
body, and brought him into an alarming state of prostration. 
It Avas now clear that something decided must be done, or the 
patient would sink ; and, on further consultation, it was agreed 
that the rib should be cut down upon, the carious part removed, 
and, if thought expedient by the knoAvledge thus acquired, a free 
opening made into the chest. The patient being etherized, a 
somewhat laborious dissection was required to expose the rib, 
on account of the accumulation of lymph over it, which had 
gradually collected, and obscured the opening into the chest. 
About an inch of the bone, in a diseased state, was excised, and 
the pleura, much thickened by inflammation, exposed. An 
aperture about an inch long, with thickened edges, was now 
seen, which, being enlarged laterally, allowed the forefinger to 
pass freely into the cavity of the thorax. It was ascertained that 
the interior of the pleura was lined with a highly vascular spongy 
tissue, bleeding on the slightest touch, which, probably being 
irritated by the retained pus, had given rise to the profuse 
hemorrhage. Being turned on his side, a large quantity of 
blood and pus ran out. 



PARACENTESIS THORACIS. 151 

From the time of the operation, he began to improve, and 
with the exception of a very sL'ght discharge of blood from the 
chest, on the day succeeding, had no farther difficulty. He is 
now, many years after, in good health. His chest is contracted 
on that side, and his shoulder greatly depressed ; otherwise he 
has the appearance of a very strong and healthy man. 

In another case (that of a boy about 16 years of age, re- 
ferred to me by Dr. Bowditch), where severe cough, emacia- 
tion, and other disagreeable symptoms, were dependent on 
empyema with an imperfect escape of pus through fistulous 
openings, all symptoms were relieved by making a free and 
direct opening into the chest. 

The last two cases are selected from quite a number which 
have occurred to me. As a general rule, I would repeat what 
I have before said, that a free incision, with the removal even 
of a piece of the rib if necessary, gives the best results where 
repeated punctures have failed. 

In regard to the excision of a portion of the rib for tumors or 
other disease, generally speaking, the danger is less of pene- 
trating the pleura than will at first be supposed. The texture 
is so thickened by inflammation as to be easily peeled from the 
bone. 



CHAPTEE Y. 
ABDOMEN. 

HERNIA. — STRANGULATED HERNIA. 

The whole treatment of strangulated hernia has been altered by 
the introduction and use of ether. Many cases which resisted 
the use of ice, depletion, and debilitating remedies, such as 
antimony and tobacco injections, are now, with the patient well 
etherized, and careful manipulations, reduced without a cutting 
operation. I have seldom had any difficulty in reducing hernias 
of large size : it is the very small hernial tumors that occur sud- 
denly after an effort, in which the taxis under ether often 
fails. After a moderate and careful use of the taxis, I have 
never delayed the operation, and have availed myself of the 
patient's being under the influence of the anesthetic to proceed 
at once to it. In skilful hands this is almost always successful ; 
and I have never had reason to believe that the patient died 
from the effects of the operation, it almost always being from 
the delay in performing it. Some cases of large hernia have 
been under my care at the Hospital, which at first appeared in 
a strangulated condition, but which were simply impacted from 
a sudden addition to an already pretty firm tumor. If the 
symptoms were not urgent, rest in a horizontal position, a 
starving diet, opiates to relieve pain, and, in some cases, com- 
pression, have, after a few days, succeeded in affording relief. 

In one case of a very small strangulated hernia, in which the 
symptoms were very urgent, and where death seemed imminent, 
I advised an immediate operation ; but the patient positively de- 
clined, preferring to die as she was. A week afterwards, to my 
surprise, I was called to her again by her physician, and found 
her still alive, and ready to have the operation done. On open- 



STRAXGULATED HERXIA. 153 

ing the tumor, the sac was found entirely gangrenous ; but the 
pressure of the stricture had been expended on this part, and 
the small loop of the intestine, though very much discolored, 
still preserved its vitality. The stricture was divided, and the 
intestine returned. The patient recovered. This case, however, 
is a very rare one. The rule should be, where the hernia is 
not at once reduced under the relaxing effects of ether, not to 
delay the operation with the idea that the tumor may be re- 
moved by local applications. 

. The distinguished surgeon, Mr. ^Villiam Lawrence, of Lon- 
don, whose treatise on Hernia still remains the best authority, 
— as do all his works on scientific subjects, — says, "The dan- 
ger to which the patient is exposed by the operation is less than 
that which he undergoes by delay. Li the latter case, inflam- 
mation and gangrene of the part, which is thus rendered inca- 
pable of exercising its functions, and extension of inflammatory 
disorder along the canal above the stricture, as well as over the 
cavity of the abdomen, with rapid exhaustion of the vital 
powers, are surely produced by a continuance of the incarcera- 
tion." And again he says : " Our conduct must not be guided 
merely by the duration of the case : the kind of strangulation, 
the nature of the symptoms, the effect of the means employed, 
and the state of the parts, must influence our determination. 
Small and recent herniae, or such as, having been kept up for a 
long time by means of a truss, are suddenly reproduced, admit 
of little delay. The strangulation is violent in such instances ; 
inflammation and gangrene soon come on. In old and large 
ruptures, which have been often down and often replaced, the 
symptoms are not so urgent, nor the necessity of operating so 
pressing." 

I propose to adduce a few cases in illustration. 

Case LXXXV. — Strangulated Femoral Hernia. Omen- 
tum forming a Cyst containing the Intestine. Large Abscess 
icithin the Jibdomen. — The subject of this case was a laborer, 
40 years old. The hernia first made its appearance five years 
before, in 1837, and was discovered filling the scrotum after a 
hard day's work. The patient was able to return it himself with 

20 



154 ABDOMEN. 

some little difficulty : he made no application, however, and 
wore no truss ; and when the intestine was occasionally pro- 
truded and a little pinched, by quiet and abstinence, he suc- 
ceeded in replacing it without medical assistance. Two years 
before, the hernia suddenly disappeared, and did not appear 
again until the time I was called to him, in 1842. 

I was requested to see him by his physician. Dr. Brown, 
under the following circumstances. Forty-eight hours before, 
while raising a heavy load, the hernia was again suddenly forced 
out, and severe pain in the abdomen immediately ensued. He 
made repeated efforts to reduce it, and the following day even 
attempted to resume his work, but fainted from pain, and was 
taken home. He did not see his physician until the next morn- 
ing, not apparently being aware of the dangerous nature of 
the disease. He was immediately bled, ice was applied to the 
hernial tumor, and all the ordinary means for the taxis resorted 
to. In the afternoon, the symptoms becoming aggravated, I 
was requested by Dr. Brown to perform the operation. 

The tumor at this time was about the size of an orange, very 
tense and painful to the touch ; and the scrotum, from the long- 
continued efforts of the patient by severe rubbing for its reduc- 
tion, had become considerably inflamed. He complained of a 
severe dragging and almost insupportable pain in the abdomen. 
On opening the hernial sac, a large mass of omentum presented, 
very red and swollen : this had an elastic feeling, as if it sur- 
rounded a mass of intestine. 

The stricture, which was formed by the external abdominal 
ring, was extremely close ; and it was with the utmost difficulty 
I was able to insinuate a director under its edge, and divide its 
fibres. This being accomplished, the strangulated parts were a 
little loosened so as to allow me, after some examination, to in- 
sert the little finger into an aperture formed by a folding of the 
omentum, and discover a knuckle of the intestine, which was 
thus almost completely encysted. By a slight pressure, this 
was easily returned into the abdomen. The reduction of the 
omentum was, however, a matter of more difficulty ; and it was 
only after a further division of the stricture, and by considerable 
management, that it was ultimately reduced. The omentum, 



STRANGULATED HERNIA. 155 

though much swollen, was not at all indurated, and was other- 
wise quite healthy. He expressed himself immediately relieved 
on the completion of the operation. 

The following morning he was free from pain In the bowels, 
which acted well after a dose of castor oil. There was a reten- 
tion of urine, which required the use of the catheter. His pulse 
was a little accelerated. On the third day, I perceived a slight 
redness in the groin, and he complained of a deep-seated pain 
in the left iliac region. The pulse was quick, countenance 
anxious, and the tongue considerably coated. On the following 
day, the redness had extended itself nearly half down the thigh, 
and over a part of the abdomen of the same side. There was 
great pain at this point, on pressure ; but the abdomen generally 
was not over-sensitive, and presented no appearance of extended 
peritoneal inflammation. His bowels were freely evacuated by 
means of castor oil, and leeches were applied to the seat of pain, 
followed by a large poultice to promote the flow of blood, and 
increase the capillary circulation. In the course of a few days, 
an indistinct fluctuation could be distinguished deep in the iliac 
region, which finally, ten days after the operation, began to dis- 
charge itself through the external abdominal ring at the upper 
part of the wound made in the operation. So far as could be 
ascertained, about a quart of pus was contained in the abscess. 
The parietes gradually contracted, and the patient recovered 
without further difficulty. 

The three points of interest in this case are, first, the disap- 
pearance of a large hernial tumor, which for three years had 
been unrestrained by a truss, and its sudden return, and Imme- 
diate strangulation by the external ring, two years afterwards. 
Second, The encysted state of the intestine, which was so com- 
pletely concealed, on the first opening of the sac, that It could not 
be exposed ; for it was only after the protruded parts had been 
relieved by a free division of the stricture, that the omentum 
could be unfolded, and the intestine discovered through a small 
aperture at Its posterior portion. Third, the formation of the 
large abscess within the abdomen. No appearances were pre- 
sented, on the evacuation of tins abscess through the abdominal 
ring, to justify the idea that any portion of the omentum had 



156 ABDOMEN. 

become gangrenous : the pus was well formed, and in all proba- 
abilitj must have been derived from a suppuration of the 
prolapsed omentum, which had been inflamed partly by the stran- 
gulation it had been subjected to, and partly from the long- 
continued and violent efforts of the patient to force it back into 
the abdomen. 

Case LXXXVI. — Strangulated Hernia. Reduction 
under Singular Circumstances. — To the above case I may 
add one of some interest, showing the powerful influence of fear 
in effecting the reduction of an apparently irreducible hernia, 
Avhich had resisted all the ordinary means of treatment. I was 
requested by a medical friend to perform the operation for a 
patient laboring under the most urgent and distressing symp- 
toms I have ever witnessed in this disease. The hernia was an 
old one, and had first become strangulated two days before. 
In addition to severe pain in the abdomen, the patient had vio- 
lent spasmodic action of the whole body, especially of the lower 
extremities, and an almost continued vomiting. Before I saw 
him, he had been thoroughly bled to syncope, ice had been 
applied to the tumor, and a tobacco enema had been adminis- 
tered, but all without effect ; and the only hopes of saving life 
appeared to be in the speedy resort to surgical means. All the 
preparations for the operation being made, as I was just on the 
point of commencing the incision, his courage gave way, and 
he obstinately determined not to submit to it. 

I then stated to him the great danger of any delay, and the 
probability of a very speedy fatal termination if the intestine 
was allowed to remain longer in its present situation. The dan- 
ger of death before his eyes seemed to have a powerful effect 
on him ; and, while I was speaking, the spasmodic action of the 
body ceased, and the patient became deadly pale. Having my 
hand on the tumor, I felt a slight relaxation in its contents. I 
immediately seized the intestine through the abdominal parietes 
with one hand, and, making a strong extension, used a slight 
compression with the other hand, on the sac ; and the hernia 
slipped back into the abdomen. His recovery was complete. 

Had it not been for the occurrence of the accidental circum- 



STRANGULATED HERNIA. 157 

stance mentioned above, I have every reason to believe that 
the mere intensity of suffering must have shortly terminated his 
existence. 

Case LXXXVII. — Strangulated Hernia. Btercoraceous 
Yomitiiig. Introduction of Fecal Matters into Air Pas- 
sages. Death. — On Sunday, July 6, 1862, a woman, 43 
years of age, was brought into the Hospital for strangulated 
hernia of five days' duration. She had suffered with an inguinal 
hernia on the right side for four years. It was reducible, and 
she wore a truss. 

A week before her admission to the Hospital, after violent 
straining, the hernia came down, and could not be reduced. 
Constant vomiting commenced, which, for three days before her 
entrance, was stercoraceous. When she entered, she was in the 
greatest state of prostration, countenance pale and livid, and 
very apathetic. She answered questions reluctantly, and only 
when strongly pressed. Stimulants were first administered to 
her. After some re-action had taken place, ether was given 
sparingly ; and she came easily under its influence. The opera- 
tion was performed with great rapidity, only occupying a few 
minutes. Some serum was found in the sac, and the intestine 
much congested. The stricture was divided, and the intestine 
was replaced. The ether was discontinued at about the middle 
of the operation. 

The edges of the wound were then brought in apposition, the 
patient breathing tranquilly, and the usual preparations made to 
return her to her bed in the ward. Suddenly the patient (who 
had made the usual groans and sighs of a person recovering 
from ether) made an effort to vomit, and was placed on her side 
to facilitate the escape of the fluids from her mouth. These efforts 
were once or twice repeated, when the face became livid, ptdse 
began to fail, and a loud subcrepitant rale could be heard all 
over the chest ; the symptoms resembling those of a person 
asphyxiated by drowning. All the usual remedies were em- 
ployed to restore the vital powers ; but the pulse and respiration 
gradually failed, and she died in the course of ten or fifteen 
minutes. 



158 ABDOMEN. 

On examination of the body, the following day, the appear- 
ances presented were these : — 

The intestines and stomach were entirely filled with a large 
quantity of yellow fluid of a very fetid odor. The mouth and 
fauces were also filled with a similar fluid. On opening the 
air-passages, this same fluid was found to have penetrated the 
most remote ramifications of the bronchi^e. 

The incarcerated intestine, which had been freed by the 
operation, showed the marks of the great constriction to which 
it had been subjected, but would probably have recovered it- 
self. 

At first sight, I thought I had met with a case of death from 
the use of ether ; but the autopsy revealed the nature of the 
case. 

The patient, as has been stated, had partially recovered from 
etherization, so as to make articular sounds. The medical gen- 
tlemen who were present at the operation had, in fact, most of 
them retired, thinking the case finished. From the recurrence 
of the efforts to vomit, partly from the great reduction of the 
vital powers, in connection with the insensibility of the glottis 
from the effects of ether, the fluids had gained a ready entrance 
into the air passages. 

The following case from the "London Medical Gazette," to 
which my attention has been called by my friend, Dr. Francis 
Minot, is interesting as illustrative of a similar occurrence, 
though of a different origin. As the case is instructive, I tran- 
scribe it. 

" St. Thomas's Hospital, April 23, 1859.— The following case 
illustrates some of the ill effects of drunkenness, and shows the 
impropriety of leaving persons in this condition wholly uncared 
for : — 

"J. W., a laborer, 32 years of age, was brought to the Hos- 
pital by the police at 7 o'clock, a.m. He had, some little time 
previously, been taken to the station-house in a state of com- 
plete and helpless intoxication ; had remained there a few hours 
without having much attention bestowed on him ; and, at the end 
of that time, his condition then exciting some alarm, he was 
brought to the Hospital. 



STRAls^GULATED HERNIA. 159 

" On admission, he was found still to be somewhat comatose ; 
but his face was livid, his breathing laborious and wheezing, 
his pulse almost imperceptible and rapid, his skin moist. He 
presented, in fact, most of the features which characterize the 
last stao^e of bronchitis. He died in the course of a few hours. 

^^ Autopsy. — Body in good condition, but anasarcous. The 
superficial veins of the brain were more loaded with blood than 
usual, and the substance of the organ was somewhat congested. 
Pericardium and heart healthy ; the cavities of the latter were 
dilated, and filled with soft black coagula ; pleura free from ad- 
hesions. 

^"^ Lungs. — Large, much inflated, but not emphysematous: 
they were crepitant throughout, and a little congested ; but there 
was no oedema. On squeezing the sectional surface of any part 
of either organ, all the cut bronchial tubes yielded tenacious 
cylinders of a dirty yellowish hue ; and, on tracing the tubes, it 
was found, that all of them, from the largest trunks to the mi- 
nutest ramifications, were filled almost completely by a material 
in some places softer, in some more tenacious, but everywhere, 
in all essential particulars, resembling that squeezed from the cut 
orifices. The mucous membrane of the tubes was deeply con- 
gested throughout, and in some instances it appeared as though 
small extravasations of blood occupied the submucous tissue. 
The mucous lining of the larynx and trachea was likewise in- 
tensely congested ; but it was not thickened, and there was no 
exudation on the surface. Under the microscope, the material 
occupying the bronchial tubes was found to present a large 
quantity of free oil, cells of potato, and innumerable fragments 
of muscular fibre, together with a good deal of stuff" of which 
the nature was not clear ; the whole being intermixed with ciliary 
epithelium, and some imperfect forms of cells belonging to the 
mucus, which cemented, as it were, the various substances into 
the form of tenacious cylinders. 

"Peritoneum healthy. Liver, of uniform, reddish-brown 
hue, congested, but healthy. Spleen, of usual size, pale, flab- 
by, and wrinkled. Pancreas, kidneys, and supra-renal capsules, 
healthy. 

"The mucous membrane of the stomach (cardiac end) was 



160 ABDOMEN. 

somewhat congested and softened ; but that of the rest of the 
organ and of the intestine was healthy, presenting, however, a 
more than ordinary quantity of mucus adhering to it. Aorta 
healthy. 

^^ Hemarhs, — It is evident, from the results of the examina- 
tion, that the man, while in his drunken state, had been continu- 
ally vomiting, or, rather, regurgitating the contents of his 
stomach ; and that, owing to his unconscious and perhaps partially 
paralyzed condition, he had drawn these continually through the 
larynx, and thence into the bronchial tubes, which had gradually 
become choked up. It is clear, too, that the irritation of the 
foreign matter had excited in the latter intense congestion, and 
copious effusion of mucus ; and that, from the combined effects 
of the abundant accumulation of vomited material, of congestion, 
and of effusion, the patient had been suffocated, and had devel- 
oped those symptoms which had simulated bronchitis. 

" From the complete way in which even the smallest bronchial 
tubes were filled, from the history, imperfect though it be, and 
from other circumstances, it is obvious that the process had been 
a gradual one : and one cannot help regretting, therefore, that 
he had not before been placed under competent supervision ; and 
that such precautionary measures, and such treatment as would 
have suggested themselves to any medical practitioner, had not 
been put in force at an early period." 

Case LXXXVIII. — Oase resembling Strangulated Her- 
nia. Difficult Diagnosis, — A girl, aged 23, entered the 
Hospital, in the medical wards, June 23, 1866 ; and, on the 
follow^ing day, was referred to me by the physician, under the 
supposition that she had strangulated hernia. She said that, 
seven weeks ago, from a strain, she felt a pain in both groins. 
Five weeks ago, while lifting a washtub, a tumor appeared sud- 
denly in each groin, which had been painful since. For the last 
week or two, she had been confined to her bed, with much pain 
in the right tumor ; had had no movement of the bowels for six 
days, in spite of the use of medicines ; and had been troubled 
with vomiting. 

The right tumor was so painful that she could not support 



STRANGULATED HERNIA. 161 

any examination without ether. This being given, a slightly 
inflamed elastic tumor, the size of a hen's egg^ was found, just 
below Poupart's ligament, on the right side, and a smaller one 
on the left. It was decided, on consultation, that though it was 
improbable that two hernias should appear at once, yet, as tliere 
had been vomiting and obstinate constipation, there was reason 
to believe that the bowel might be in the tumor, and delay might 
be fatal. It was therefore agreed to make an exploratory opera- 
tion,, as, in case it turned out to be a suppurating, glandular 
tumor, this would afford relief. 

The right tumor was, therefore, cut down upon ; and, the fascia 
covering it being exposed, there was a dark appearance under 
it, like the sac of a hernia. This being cut into, pus escaped, 
and the tumor was found to be glandular. A similar operation 
was done on the other side. 

On recovering from the ether, she expressed herself greatly 
relieved, the pain previously being almost insufferable. 

On the following day, there had been a slight evacuation from 
an enema ; but no further evacuation, notwithstanding a dose of 
senna. The senna being repeated, at stated intervals, on the 
second day after the operation, and the seventh of the constipa- 
tion, the bowels were finally acted upon. After this, she began 
to recover. 

In connection with this case, I would mention the following : — 

I was requested to see a patient, in the spring of 1866, 
who had had, periodically, for a number of years, a tumor ap- 
pear in the right groin, attended with severe disturbance of the 
digestive organs, with constipation. This had recurred, as 
usual, and the symptoms had been treated without relief. 

On examination, I detected a hernial tumor in an inflamed 
condition, which was at once cut down upon, and the sac and 
the intestine found gangrenous. The upper and lower open- 
incrs of the intestine were about lar^e enouoh to admit a small- 
sized bougie, their parietes being greatly thickened. 

The patient died about three days afterwards ; it being impos- 
sible to get any evacuation, though injections were thrown into 
the upper opening. 

At the autopsy, the upper intestine was found flatly applied 

21 



162 ABDOMEN. 

to the edges of the right femoral ring, so as, together with the 
inflammatory condition of the intestine, to prevent any passage 
of the contents. In the same side of the uterus was found a 
fibrous tumor the size of an orange, which, by the enlarge- 
ment of that organ at the catamenial periods, might possibly 
explain the periodical forcing down of the rupture. 

Aiany years since, when a student, I assisted Dr. John C. 
Warren in an operation on a lady who had been treated by 
a physician for bilious colic for a number of days, when a small 
tumor in the groin was detected. 

On Dr. Warren's being called, he found what appeared to be 
an enlarged gland there. As the symptoms were urgent, an 
operation was done. The gland was exposed, and dissected 
up. Under it was discovered the end of a knuckle of intestine, 
in a dark state, just projecting from the femoral ring. 

The constriction was relieved, and the intestine returned ; but 
the patient died. 

I have met myself witii a similar small strangulated hernia, 
concealed by an enlarged gland ; but fortunately got the case in 
time to save the patient. As a point of practice, therefore, it 
would seem proper, where the symptoms of strangulated hernia 
are present, to explore, although the nature of the tumor may 
be doubtful. 

Case LXXXIX. — Strangulated Hernia, with Unusual 
A.ppearances . — April 30, 1865, a woman, 27 years of age, 
entered the Hospital, with a strangulated inguinal hernia of the 
right side, of two days' duration. She had been troubled with 
a small reducible hernia some years, which had been forced 
down, and less easily retained for the last fortnight. She now 
had intense pain, vomiting, and all the symptoms of strangu- 
lation. 

On opening the sac, a little bloody fluid escaped, and what 
seemed to be the red and swollen intestine presented. Xo 
probe, however, could be made to penetrate around its margin 
into the ring, I requested my colleague. Dr. Clark, to examine 
it ; and he finally discovered a small aperture at the inner side 
of the tumor, where a probe penetrated. Here I incised the 



STRANGULATED HEENIA. 163 

tendon ; and,, after much manipulation, the intestine was reduced, 
and a large quantity of sero-sanguineous matter escaped from 
the abdominal cavity. What the obstacle was in this case, I am 
unable to decide. The most probable explanation is, that the 
intestine had pushed before it a very thin layer of omentum, 
which was firmly adherent to it, and also to the margin of the 
sac, with the exception of the small opening where the probe 
penetrated. 

The patient had a good recovery. 

Case XC. — Strangulated Hernia in a Child one year 
old. — A child was brought into the Hospital, March 20, 
1863, with a hard tumor in the upper part of the left side of the 
scrotum. There had been great suffering for twenty -four hours, 
constant vomiting, and complete retention of urine. The mother 
said that, ever since birth, the child had had a tumor, sometimes 
on one side of the scrotum, and sometimes on the other. It 
had, however, never before been hard, nor had it at any time 
given rise to any inconvenience. Latterly she had observed a 
tumor only on the left side, where it now appears. Dr. Blake, 
formerly house-surgeon at the Hospital, saw the case, and, sus- 
pecting its nature, sent it into the house. The child seemed to 
be in great pain, and strenuously resisted any examination. The 
tumor was very tense, globular, and had the appearance of a 
hydrocele of the spermatic cord. When placed in strong sun- 
light, however, it was not at all translucent. On pressure, it 
was quite unyielding. In order the better to investigate the 
case, the child was placed under the influence of ether. The tu- 
mor, being seized by the fingers and thumb of the right hand, 
was firmly compressed. The left hand, being placed at the root 
of the tumor, made a traction so as to work the intestines through 
the neck of the sack, in the case of its being a hernia. It was 
soon found tliat the tumor gradually became softer under the 
pressure exerted, and half of it disappeared, leaving still a 
hard lump in the groin. The pressure being continued, the re- 
maining portion suddenly retreated into the abdomen. It might 
have been stated, that an effort at reduction had been made before 
the administration of the ether, but without producing the slight- 



164 ABDOMEN. 

est eiFect ; and a surgical operation would undoubtedly have been 
required by the urgency of the symptoms, had it not been for 
the assistance afforded by the use of ether. This is the earliest 
age at which I have ever seen strangulation occur in a hernia. 

Eadical Cure of Hernia. — Within the last twenty years, 
operations for the radical cure of hernia have attracted con- 
siderable attention ; and for a disease so common, so incon- 
venient, and in some cases so dangerous, it is remarkable that 
no safe and effectual operation has yet been discovered for its 
relief. In 1852, Dr. George Hayward, Dr. S. Parkman, and 
myself, were appointed a Committee of the American Medical 
Association to prepare a report on this subject. In that paper, 
I mentioned a number of cases of small hernia which had been 
treated with success by the injection of stimulating liquids in 
the neighborhood of the neck of the sac, in the manner practised 
by the distinguished Professor Pancoast of Philadelphia. In 
some of these cases, as I have since been able to convince my- 
self, the cure was permanent. Since then, many different 
methods have been proposed, some of which I have tried with 
success. The one most in ffivor at the present moment is that 
by Mr. John Wood, of King's-College Hospital, London, which 
has been frequently performed in this city. It consists, essen- 
tially, in the constriction and partial obliteration of the inguinal 
canal by means of a subcutaneous suture or ligature. 

The method proposed by Dr. Pancoast, referred to above, 
may be described as follows : — 

The contents of the hernial sac being returned into the abdo- 
men, and the ring explored to ascertain that no portion of the 
intestine protrudes, the pad of a well-fitting truss is slipped 
down so as to make pressure on the inguinal canal, and prevent 
any escape of the hernia. With the forefinger of the left hand, 
the spermatic cord, as it passes out from the external inguinal 
opening, is pressed upwards on the pelvic bone, so as to prevent 
it from being injured. A delicate trocar and canula, the latter 
having fitted to it a small Anel's syringe, is now carefully but 
firmly forced through the integuments with a rotatory motion to 
facilitate its progress, and pushed forwards till it enters the ex- 



RADICAL CURE OF HERNIA. 165 

ternal inguinal ring, or neck of the sac. The trocar being now 
■withdrawn, the canula is kept firmly in place, and twenty or 
thirty drops of the tincture of iodine, tincture of cantharides, 
or sulphuric ether, thrown in, and lodged in the neck of the sac, 
when this is practicable, or else in the vicinity of the external 
abdominal ring. Subsequently, a small compress is applied 
over the minute wound made by the trocar, the pad of the truss 
slipped down over it, and the patient directed, for a week or 
two, to maintain the recumbent position. 

In addition to the injection, in some of the operations, a 
tenotomy knife was previously introduced, and the internal sur- 
face of the neck of the sac scarified. The wound made by the 
knife in these cases much facilitated the subsequent introduction 
of the trocar, which is with some difficulty worked throuoh the 
integuments. In no instance did any bad result follow, the pain 
and inconvenience hardly amounting to that presented in a case 
of hydrocele treated by injection, or in any simple operation. 

The following case, attended with success, will serve as an 
illustration of the course generally pursued : — 

Case XCI. — Radical Cure of Congenital Inguinal Her- 
nia. — A male child 3 years of age, with congenital inguinal 
hernia of the right side, was brought to the Hospital to obtain 
relief, if it was possible, as no truss had been found to retain 
the protruded intestine in the abdomen, and the pain and incon- 
venience from the infirmity were great. A tumor, the size of a 
small orange, was found to occupy the scrotum. By a little 
manipulation, the contents were ascertained to be a portion of 
omentum, a loop of intestine, and the testicle,^ — the whole 
of which, by care, could be easily returned into the abdomen. 

The question was, whether the testicle could be separated from 
the other parts (the adhesions being quite intimate between 
them) so as to admit the return of the intestine and omentum 
into the abdomen, leaving the testicle in the scrotum. This 
being found possible, the operation was performed as follows : 
The intestine and omentum being returned into the abdomen, 
and the testicle prevented from following, the spermatic chord 
was held out of the wav in the manner stated above. A sub- 



166 ABDOMEN. 

cutaneous incision was then made with a cataract needle, the point 
of which was carried into the sac, and the neck scarified in dif- 
ferent directions. Through the aperture thus made, a small 
trocar and canula were introduced : the former being withdrawn 
the syringe was adapted, and thirty drops of sulphuric ether 
were injected. The truss was then applied. 

The operation was performed Oct. 28, 1847. There was 
every prosj^ect of success until Dec. 9th, when, during a violent 
paroxysm of crying, the hernia was forced down. On the 12th, 
the hernia was returned, and the injection repeated. It result- 
ed, on the following day, in a swelling of the scrotum, such as 
is observed after the injection for hydrocele. Dec. 22d, the 
report was made that the hernia came slightly down, and was 
returned with difficulty, " the aperture being apparently quite 
small." By the end of the month, it was stated that the hernia 
was perfectly retained. I have been informed since that the 
cure was permanent. 

During the treatment of this case, a slight superficial sup- 
puration took place under the pad of the truss, which, the 
patient being somewhat fractious, was necessarily applied pretty 
firmly, to prevent the recurrence of the hernia after the opera- 
tion. 

In a large proportion of the other cases operated on, the 
patient experienced much relief, though still obliged to wear a 
truss. In one case, where the hernia was quite large, no relief 
was experienced. A female, with a double femoral hernia, on 
whom the scarification and injection were once or twice repeated, 
expressed herself much benefited by the operation ; the hernia 
being retained, and the suffering previously experienced much 
relieved. Another patient, a laboring man, was seen by me six 
months after the operation : the rupture had not recurred, but 
he still wore a truss. Previous to this time, he had been unable 
to work without forcing down the intestine under the pad, caus- 
ing him much pain and ill health. 

From a comparatively limited experience, I derive the fol- 
lowing conclusions : — 

First, That the operation, when carefully performed, is safe. 

Second, That, in ruptures where the neck of the sac is small. 



RADICAL CURE OF HERXIA. 167 

and the abdominal aperture not too much enlarged by repeated 
descents of the hernia, there is a prospect of a radical cure. 

Third, That, in most cases, the operation mitigates the infirm- 
ity, allowing the hernia to be more readily retained by the or- 
dinary mechanical means. 

Since the above operations, I have frequently performed that 
of Wiitzer, which consists of the invagination of the skin of 
the scrotum into the inguinal canal, and retaining it there by a 
proper instrument until adhesions have been formed. I have 
also done some operations by invaginating the skin, retaining it 
in place by means of a stitch, and applying caustic to the cul- 
de-sac, for the purpose of producing inflammation, adhesion, 
and a solid plug. Some of these cases have succeeded ; others 
have failed, the hernia forcing itself down again behind the 
invaginated skin. 

Case XCII. — Wiitzer^ s Opeyxition for Cure. — In June, 
1860, a young man, 28 years of age, entered the Hospital for 
the purpose of having an operation performed to effect the 
radical cure of an inguinal hernia on the right side, which 
had existed for three years, and was as large as a hen's Qgg. 
He was placed upon the operating table : the hernia was re- 
duced, and, after introducing a portion of the skin of the scrotum 
to form a plug, Wlitzer's instrument was applied, the needle 
passing through the invaginated scrotum, the hernial sac above 
the internal ring, and the abdominal parietes, and secured by a 
clamp. 

On the second day, there was slight inflammation around the 
needle ; and on the fifth day, when the needle was removed, pus 
appeared in the wound. On the eleventh day, lymph was dis- 
cernible along the course of the spermatic cord, which after five 
days formed a firm plug, sufl&cient to confine the intestine in the 
abdominal cavity, excepting upon violent exertion. 

Case XCIII. — Wlltzers Operation for Cure. — Soon 
after the above operation was performed, a boy five and a half 
years old was brought to the Hospital on account of a congeni- 
tal inguinal hernia on the right side, which formed a tumor 



168 ABDOMEN". 

descending nearly to the knees. It was easily reduced. He 
was etherized, and Wiitzer's instrument was applied, as in the 
previous case. The needle caused sufficient irritation to give 
rise to ulceration, by which a passage was made allowing it to 
slip down about three-quarters of an inch. On the seventh day, 
an effusion of lymph had occurred along the track of the sper- 
matic cord ; but, two days later, the hernial protrusion was 
noticed behind the plug. 

Subsequently he was again etherized, a fold of the scrotum 
was invaginated, and three ligatures were passed through it and 
the abdominal parietes, and secured by means of pieces of 
bougie. There was much inflammation and swelling ; and, on 
the fifth day, the ligatures were removed. The result was in 
every way satisfactory. 

ARTIFICIAL ANUS. 

Artificial anus is an affection generally caused by the slough- 
ing of the intestine in strangulated hernia, although occasionally 
the result of abscess and penetrating wounds. Sometimes a 
small portion only of the calibre of the intestine is destroyed, 
the bowel becoming attached to the parietes of the abdomen, and 
a fistulous opening is the result, usually amenable to the ordi- 
nary method of treatment. At other times, a whole loop of the 
bowel sloughs oiF, and both ends of the intestine unite to the 
abdominal walls, leaving an opening from which the feces are 
constantly discharged, only to be remedied by surgical means. 

Cases of the latter character are of unusual occurrence ; and 
the means for their strictly scientific treatment by surgical opera- 
tion have not, until within a few years, been fully established. 
Tlie one I intend to relate is, as far as I am aware, one of the 
first successfully operated upon after the method of Dupuytren 
in this part of the country. 

A patient with this affliction is one that may fully claim the 
sympathies of those called upon to administer to and alleviate 
human suffering. Suspended, as it were, in the possession of 
his mental facukies, between life and death, he is destined, un- 
less relieved, to drag out a miserable existence, an object of 



ARTIFICIAL ANUS. 169 

disgust to himself and a burden to his friends, or to sink, worn 
out by pain and the emaciation produced by deficient nutrition. 
It is a source of great satisfaction, therefore, to the surgeon, if 
he can be the means of relieving so distressing a misfortune. 

Case XCIY. — Artificial Anus from Strangulated Her- 
nia. Fistulous Openings in the Thigh discharging Fecal 
Matter. Operation. Oure. — The patient, of whose case I 
propose to give an account, was sent to me by Dr. Brown, of 
Nova Scotia, in June, 1847. She was thirty-four years old, the 
mother of six children, and, previous to the occurrence of the 
present accident, of good constitution. A small crural hernia 
had existed on the right side for an indefinite period of time. 

Dr. Brown was called to her fourteen months before, and 
found her laboring under a strangulated hernia of forty-eight 
hours' duration. An operation was immediately performed ; but, 
on opening the sac, the intestine was exposed in a gangrenous 
state. The stricture was therefore divided, and the intestine left 
in the Avound. At the end of a week, the sphacelated portion 
separated, and the feces flowed freely through the opening. 
After some time, she partially regained her health, was able to 
sit up, and finally to work moderately, until the following Sep- 
tember, when abscesses began to form in different parts of the 
thigh. From this period, she gradually lost her flesh, and de- 
clined in strength. Two of the abscesses were opened by the 
lancet ; the others, on the under surface of the limb, opened and 
discharged spontaneously. Pus at first issued, followed by 
fecal matter ; and great suffering attended the eff'usion of the 
latter into the soft parts. Until within a^ few weeks previous to 
her coming under my care, there were occasional fecal discharges 
per anum ; but the greater proportion of matter was evacuated 
through the various fistulous openings. 

She arrived in town in the early part of June, 1847, and 
entered the Hospital. 

She was extremely weak and emaciated ; the countenance 
pale, nearly exsanguineous, indicating the almost total failure of 
the assimilating process. From long confinement, she had 
become nervous and timorous, hardly allowing the slightest ex- 

22 



170 ABDOMEN. 

amination ; and, on the day before her entrance, she was so 
completely homesick, that, notwithstanding the great trouble 
and expense undergone by her physician and friends to enable 
her to accomplish her journey to Boston, she insisted on return- 
ing home at once by the same vessel in which she came. After 
a day or two of consideration, however, and by a little per- 
suasion, she was induced to change her mind. 

The position of the patient was almost entirely on her back. 
The feces, in a very liquid state, were constantly running out 
through two openings in the groin, and three in the posterior 
part of the thigh. The right limb was drawn up almost to a 
right angle with the body, and the whole thigh much enlarged 
and hardened. The skin around the openings in the groin had 
a red, irritated look, was thickened almost to callosity, and ex- 
coriated. The openings were quite small, so as hardly to admit 
an instrument larger than a common director. 

A nourishing diet was allowed, and great cleanliness of the 
wounds enjoined, with the more especial object of preventing 
the painful excoriations. 

The situation of the intestine could not at first be determined, 
which added to the embarrassment of the case. In those of a 
similar nature which I had an opportunity of seeing abroad, 
under the care of Dupuytren, the intestine opened on the sur- 
face of the abdomen, by a large aperture ; and there was no diffi- 
culty in exploring at once the end of the bowel, with the finger 
or by instruments. In the present instance, the fistulous open- 
ings ran in every direction : those in the groin were immediately 
in the neighborhood of the probable orifice of the artificial anus, 
allowing a probe to penetrate for its entire length. 

I therefore determined to dilate the two latter openings, which 
i^^as done very gradually, by sponge-tents, on account of the 
sensitiveness of the patient to any manipulations ; and it re- 
quired the persevering application of this method for a month, 
before the two ends of the intestine could be with certainty dis- 
tinguished. This, however, was finally accomplished, and a 
gum-elastic bougie passed into the upper, and another into the 
lower, orifices of the intestine. The bougie first penetrated 
through a thick, callous mass of integument, then through the 



ARTIFICIAL ANUS. 171 

muscular or tendinous covering of the abdomen, in all about an 
inch in depth, when the septum, or spur, as it has been called, 
which separates the two ends, was encountered, and with diffi- 
culty entered, being so closely applied to the parietes of the ab- 
domen as to prevent the least passage of matter from the upper 
into the lower part of the bowel. There had not been, in fact, 
for two months, the slightest fecal discharge per anum. The 
intestinal ends seemed to lie parallel to each other, so that the 
bougies introduced for exploring made but a very slight angle. 
The patient still remained nervous, and quite feeble. 

I directed that the sponge-tents should be continued ; also 
that a pint of oatmeal gruel should be given, per anum, daily, 
for the purpose both of stimulating the intestinal coats to the 
performance of their natural functions, and with the object of 
enlarging the calibre of the bowel, which must have become 
much contracted from lono- disuse. 

On the follow^ing day, I found that some scybala had come 
away with the enema ; and, on the next day, the injected fluid 
made its appearance at the apertures in the groin. 

In the course of a few days, the principal opening had be- 
come so dilated, that, by a steady and patiently applied force, 
I could insinuate the little finger quite down to the intestine. 
The septum could now be distinctly felt lying against the wall 
of the abdomen, and be hooked up so as to permit the end of 
the finger to be carried into the lower portion. Its sensation 
was that of a delicate membrane, like the coronary valves of the 
aorta, though somewhat more resisting. A director was now 
carried down, at the side of the finger, for the purpose of keep- 
ing the intestine open, a gum-elastic catheter passed in, and a 
quantity of warm water injected, to make sure that the lower 
orifice had been found. This water afterwards appeared, and 
was discharged per vias naturales. 

The patient being well prepared, I determined to apply the 
enterotome, which was done July 12th. Having made sure of the 
lower opening by a director, as on the day previous, the male 
branch of Dupuytren's enterotome was carried into the lower 
intestine : the director was then Avithdrawn, and the female 
branch introduced with ease into the upper. The two parts of 



172 ABDOMEN. 

the instrument now occupied nearly the whole calibre of the di- 
lated passage leading to the gut. I found at once that it was 
impossible to lock them ; for the jaws of the female portion 
would not allow of sufficient motion, at the hinge, to lock with 
the other part of the instrument. If the intestine had opened 
directly on the abdominal surface, there would have been no 
difficulty ; but the locking of the forceps under the existing cir- 
cumstances w^as impracticable. 

I therefore withdrew the instrument, and had recourse to 
another, which has since proved much better than the entero- 
tome of Dupuytren. This instrument was four and a half 
inches in length. Its handle was constructed . with a screw- 
vice, and the joint with a movable pivot, as in that of Dupuy- 
tren : the blades, however, were different. In the place of one 
blade being received into a groove in the other, they were ser- 
rated, like the polypus forceps, for the space of three inches. 
The blades, being introduced in the manner already described, 
were locked without difficulty, and at once brought together as 
tightly as the screw would permit. 

On the next day, I found her free from pain. She had com- 
plained a little for a few hours after the instrument had been 
put in place ; but there was a question whether this might not 
have arisen from fear. 

The fecal matters passed by the side of the instrument, and 
warm water Avas daily injected into the wound, to prevent any 
obstruction. She had also an enema daily, which kept the 
lower bowel in action. 

On July 15th, three days after its application, the instrument 
came away. In the jaws of the forceps, and bearing the im- 
press of the teeth, was a blackish slough, two inches and a 
half long, four lines wide, and about three thick. The finger, 
passed into the orifice, could distinguish an opening, correspond- 
ing in size to the slough, between the two ends of the intestine, 
the edges of which were greatly thickened and fleshy, imparting 
a sensation entirely unlike that of a i'ew days previous. 

This examination was conducted with the greatest delicacy, 
from fear of destroying the adhesions, which must have been, 
of course, at this early period, of the slightest kind. 



ARTIFICIAL ANUS. 173 

In the afternoon, she had a small fecal tliscliarge through the 
wound. She complained of no pain, and there was no tender- 
ness of the abdomen. 

On the following da}^ the 16th, she was quite comfortable, 
had had a free dejection per anuni from an enema, more slimy in 
its character than usual. There had been no discharge from the 
wound since the day before. A gentle compression was made 
by means of a compress and bandage on the openings in the 
groin, and the orifices ordered to be touched daily with the ni- 
trate of silver. 

She improved in health, rapidly acquired her strength, and 
had no farther discharge at the artificial anus from the day 
of the separation of the instrument until she left the Hospital, 
at which time the openings in the groin had almost completely 
cicatrized. 

On July 29th, being very eager to return home, she was dis- 
charged at her own request, but against my wishes, as I was 
anxious to watch the progress of the case to its very close. 

From a desire to learn the final result of this case, I after- 
wards addressed a letter to Dr. Brown, of Horton, N.S., her 
physician, and received a reply bearing date May 5, 1848. In 
his answer, this gentleman informed me, that, immediately upon 
her return, she was greatly •improved both in health and spirits, 
the feces had their natural exit, and every thing looked very 
promising. In a short time, however, owing to over-indulgence 
in the use of coarse, flatulent food, and the want of that general 
surveillance so necessary for this class of patients, fecal matters 
had again appeared at the old orifice, as well as at several places 
on the hip, some of which were fresh outlets. This was the 
condition of things in December, when Dr. Brown was sum- 
moned to a meetins: of the leoislature at Halifax. 

"On my return in April," writes this gentleman, "about a 
week ago, I was quite taken by surprise to find our patient per- 
fectly recovered, looking as plump and gay as ever, and busily 
employed about her house. Being in haste, and she being busy, 
I did not examine her ; but she informed me, that all the ulcers, 
as well as the original outlet, were entirely healed, except one 
new one, and that had not discharo-ed fecal matter for some 



174 ABDOMEN. 

time, and was in fact nearly healed ; that the hip had greatly 
decreased in size, and had assumed quite a natural appearance ; 
that her bowels were entirely regular, and she could take any 
kind of food without the least inconvenience. She even said 
she had not enjoyed so good general health for several years 
previous to her misfortune as now." 

On reviewing the above case, it will be perceived that it pre- 
sented difficulties of a formidable character. In the first place, 
the extreme debility and emaciation of the patient, and her great 
mental depression, were obstacles almost as troublesome to con- 
tend with as the disease itself. Twice, after much labor had 
been expended, and some progress made in the preliminary 
treatment, she insisted on relinquishing it at once, and returning 
home ; and, on the day when the instrument was to be applied, 
she declared that slie was certain she must die the followins^ 
night, and that it was quite useless to attempt the operation. 
These depressed turns generally passed off after a time, and then 
the patient was very urgent to have the treatment continued ; 
but, for the moment, they were sufficiently discouraging to the 
surgeon. 

The numerous fistulous openings, with the effi^ision of fecal 
matter into the groin and back part of the thigh, occasioned 
considerable embarrassment in pursuing the treatment for dis- 
covering the end of the intestine. Added to this, and caused 
by it, the thighs were flexed nearly to a right angle with the 
body, and w^ere constantly in the way of the instruments used 
for exploring the artificial openings. 

The instrument used, I conceive to possess great advantages 
over that of Dupuytren. In fact, it consisted of, or may 
be almost exactly represented by, a common pair of old- 
fashioned polypus forceps, with the branches detached, and 
united by a movable pivot, instead of a fixed joint ; the handles 
perforated with a screw-vice, and the jaws serrated throughout. 
It is less clumsy than that of Dupuytren, causes more complete 
strangulation, and does its work in less than half the time. By 
an examination of the cases of this distinguished French surgeon, 
it will be found that the enterotome generally separated about 
the seventh or eighth day ; in the present instance, it came away 



ARTIFICIAL ANUS. 175 

on the third, yet no effusion or other evil consequence resulted, 
although the patient was as little provided with the materials for 
forming plastic lymph as can well be imagined. 

In the relation of this case, we have only mentioned the 
course of treatment ordinarily pursued by Dupuytren, without 
alluding to the methods of Physick, Gross, and others, in this 
country or in Europe, who have done so much to advance this 
branch of surgery. 

Case XCV. — Artificial Anus in an Infant. Fecal Dis- 
charge from the Navel. Prola'pse of the Intestine. Opera- 
tion. Death. — A case of a similar kind to that narrated 
occurred to me in an infant, some years since ; and, as it illus- 
trates one of the accidents liable to take place at any moment 
in patients laboring under this unfortunate affection, namely, a 
prolapse of the end of the bowel, the details may be here given. 

I was requested, by the medical attendant of the family, to 
see an infant eight months old, and received the following his- 
tory from him. He was first called to it when three wrecks old : 
the parents stated to him, that, for a few days after its birth, it 
was in much distress, and had no alvine evacuation until the 
cord separated, when an exudation took place at the navel, fol- 
lowed by much relief. Shortly after, a small red tumor ap- 
peared at this spot, from the central portion of which the fecal 
evacuations occurred : there was no discharge per anum. He 
directed them to make use of a compress and bandage over the 
tumor ; and, under this treatment, the child began to have 
evacuations by the anus, to gain strength and flesh. I advised 
that this treatment should be persevered in. 

About two months after, from a sudden exertion, two tumors 
protruded from the navel, attended with some constitutional 
symptoms, and an entire stoppage of the evacuations. I saw 
the patient two days afterwards, and at once recognized a pro- 
lapsus of both ends of the intestine. The tumors lay across the 
abdomen, one to the right side, the other to the left ; one por- 
tion, which proved to be the lower, was dark-colored, and more 
contracted than the other. The second or upper part of the 
bowel was large, covered with mucus, and the vermicular motion 



176 ABDOMEIT. 

could be distinctly seen in it. An eiFort had already been made 
to reduce them into the abdomen, but without effect ; and a 
proposition had been made by some physician, who had seen 
the case, to apply a ligature to the root. This was advised in 
doubt as to the exact nature of the affection ; and, in fact, the 
parts were so changed that they were with difficulty distin- 
o^uished as belono^ino^ to the intestinal canal. 

The child being cold, its pulse small, and having every ap- 
pearance of rapidly sinking, I declined, for the moment, any 
operation, but advised stimulants, and agreed, if it revived, to 
attempt an operation on the following day, for the purpose of 
returning the bowel. 

On the next morning, the child having revived under the 
treatment suggested, the following operation was practised : A 
small neck or tunnel existed at the navel where the intestine 
protruded, being, in fact, the common everted orifice for the two 
openings of the bowel. An incision was made at this spot, 
being within the peritoneum, though protruded from the abdom- 
inal cavity. The two ends of the intestine, as they issued, were 
now seized with a blunt hook, and slight traction made on them. 
The inverted portion slowly began to recede ; and, by continuing 
this manoeuvre, at the same time using some external pressure 
on the tumor, it gradually returned into the interior of the ab- 
domen. The neck of the tumor, where the incision was made, 
and which represented the tunnel-shaped portion, was retained 
outside, so as to prevent the effusion of fecal matters through 
it into the peritoneum. Immediately on the return of the bowel, 
free evacuations took place from the anus, with great apparent 
relief. The patient, however, did not rally, but sunk, and died 
on the next day. 

An examination after death presented no peritoneal inflam- 
mation, or effusion ; and no attempt seemed to have been made 
by nature to close the incision of the operation, showing the 
low state of the vital powers at the time it was done. The 
upper portion of the bowel which had been returned, looked 
comparatively healthy : the lower was quite dark-colored, and 
showed the effects of the partial strangulation ; an invagination 
of its coats for about an inch also was discerned. 



AKTIFICIAL ANUS. 177 

Case XCVI. — Artificial Anus fi^om Injury. Operation. 
Cure. — May, 1859. A man, aged 29, was thrown from a 
sleigh about two years since, and alighted on the sharp point 
of the rail of a fence, which penetrated the left side of the 
abdomen, in the iliac and inguinal regions, producing a wound 
four or five inches in length, allowing the intestines to escape. 
A physician being called, the contents of the abdomen were 
replaced, and the wound closed by sutures. Pretty severe ab- 
dominal symptoms supervened ; and, at the end of a week, fecal 
matter began to issue from that portion of the wound near the 
anterior superior spinous process of the ilium. He was confined 
twelve weeks to his bed, after which he was able to get up and 
move about, though much reduced in strength. The fecal mat- 
ter continued to discharge from the wound from that time until 
the present operation. 

The patient was a large, powerful man, over six feet in height ; 
and although he was able to do some work, yet his usefulness had 
been in a great measure impaired by the accident, and the in- 
firmity consequent upon it. He entered the Hospital on May 6, 
1859, to see if any thing could be done for his relief. I was 
encouraged by the success of a previous case to operate, the 
condition of thins^s beino^ as follows : — 

On the left side of the pelvis, about an inch below its brim, 
and in the neighborhood of the anterior superior spinous process 
of the ilium, was a puckered aperture, about large enough to per- 
mit the entrance of the little finger, surrounded by a red, indu- 
rated margin. Extending from this, a little upwards and also 
downwards, to the pubes, was a long scar, which remained from 
his previous wound. A probe, being passed into the wound up- 
wards, penetrated three or four inches freely, as if superficially, 
and under the integuments : it could be passed downwards in the 
same manner without obstruction. The impression given by this 
examination would lead one to suppose, that the fecal matters 
must have an exit under the integuments, and afterwards pass 
out by a fistulous passage. This supposition, however, proved 
subsequently to be incorrect. The fecal discharges took place 
from the artificial opening at irregular intervals, two or three 
times in the day, were beyond the control of the patient, and 

23 



178 ABDOMEN. 

were partly solid, partly liquid ; their consistence depending 
pretty much on the character of the food made use of. In 
addition, he had a small operation, once or twice a day, from 
the natural passage ; this being voluntary, indicated that the 
barrier between the two portions of the intestine was not com- 
plete. He did not suffer particularly from colic or indigestion. 

The patient being etherized, the little finger was passed freely 
in an upward direction, into the artificial anus, and an incision 
made upwards of about an inch in length, towards the edge 
of the pelvis, which at once exposed the intestine, showing 
that the two ends came quite up to the external orifice. The 
septum between the two could now not only be readily seen, 
and taken between the fingers, but could even be drawn out 
externally. The finger was passed up into the upper portion of 
the intestine, and downwards into the lowxr, which seemed, 
so far as could thus be ascertained, to be the sigmoid flexure 
of the colon. The very superficial appearance presented by the 
probe, when passed in, was found to be due to the thinness of 
the integuments, occasioned by the injury. The septum being 
carefully examined, the enterotome of Dupuytren was applied, 
and screwed up to make a moderate amount of pressure. In 
order to maintain the instrument perfectly firm, as it was on 
the side, and not on the front, of the body, it was necessary to 
pad it with cotton-batting, and secure it by a bandage around 
the hips. 

On recovering from the ether, he made no complaint of pain. 
He was put on a diet of water-gruel, passed a good night, and on 
the following day, May 11th, was quite free from pain. He was 
as well on the next day. On the 13th, I found that, during the 
night, he had complained of some pain in the right side of the 
abdomen, requiring the application of hot fomentations and an 
opiate. At the time of my visit, he was relieved. He passed 
wind, both through the natural and artificial anus. I stopped 
the drinking of cold water, in which he had been indulging freely 
without my consent. 

On the 15th, he was doing well : two small pellets of fecal 
matter passed from the artificial opening on the night previous ; 
wind was passed through both the natural and artificial passages ; 
the pulse eighty-one. 



ILIAC TUMOR. 179 

On the 17th, I found the instrument had come away during 
the night without the knowledge of the patient, and discovered a 
small, thin, dried piece of intestine in its jaws, an inch and three- 
quarters in length, looking like a bit of parchment. He was 
entirely free from pain, and without any distention of the abdo- 
men. The wound was dressed with a pledget of lint, and a bit 
of adhesive plaster was placed over it to produce a slight com- 
pression. 

From this time, the fecal matters resumed their natural 
course. It was found, however, after a time, that an obstruction 
occurred in their passage, about a couple of inches below the 
aperture ; and, on investigation, it was discovered that the intes- 
tine, at this spot, turned short on itself. A second operation 
was therefore done, of hooking up this second spur, pulling it 
up to the external aperture, and applying the enterotome. The 
result was the same as before ; the instrument coming away on 
the third or fourth day, without having produced any constitu- 
tional symptoms. 

The contents of the intestines, after this, took a natural course. 

The following year, I did a plastic operation, for sliding a bit 
of skin over a fistulous opening which still remained, and 
through which, occasionally, there was a serous discharge. 
Since then, I have not heard from him. 

ILIAC TUMOR. 

In this connection may be mentioned some tumors in the 
right iliac region, which occasionally lead to abscess, and fistu 
lous openings on the parietes of the abdomen. In one instance, 
a man who had been a tailor changed his vocation at a late 
period of life, and turned farmer. The stooping position in 
working was, after a time, followed by a pain and swelling in 
the right iliac region. Very severe symptoms followed ; and, 
finally, abscesses broke in different directions over the abdo- 
men, throuo'h which fecal matter was discharged. In this 
condition, a year or two afterwards, he entered the Hospital, 
completely disabled, and unable to use his right leg, partly 
from stiffness of the hip-joint, owing to the inflammatory action 
in the neio^hborhood. 



180 ABDOMEN. 

After a series of operations, the various fistulse were explored, 
dilated, and healed, with the exception of one leading to the 
intestine, which, so far as could l>e discovered from its very deep 
situation, on account of the lymph deposited over it, was the 
coecum, — being nearly three inches from the surface of the ab- 
domen. The fecal matter was now discharged through a single 
opening. By this means, the irritation in the integuments was 
relieved, and he partially recovered the use of his right leg. 
He went into the country to recover strength for the final opera- 
tion, and died there suddenly a month or two afterwards, so 
far as I could ascertain, from some other affection. 

Shortly afterwards, another patient applied to me in a similar 
condition, the abscess having been brought on by a similar 
change of life and exercise. Probably it was in some way con- 
nected with the iliac muscles. He was too emaciated and feeble 
to undergo any operation, and, in fact, declined any. 

I removed for him, however, a cancer situated on the end 
of his tongue, by ligature, which had caused him much trouble, 
and prevented him from taking his food in comfort. 

Not long since, I had under my care a lady — past the crit- 
ical season of life — who was seized, Jan. 1st, with a sharp 
pain, with tenderness in the right iliac region, preceded by 
some days' uneasiness in that quarter. She was treated by rest, 
mild purgatives, and fomentations. She recovered in about a 
fortnight. Feb. 1st, four weeks from the first attack, she was 
again seized, more violently than before, after having taken a 
long walk, and been much exposed to a cold draught. 

An elastic tumor appeared gradually, in the course of two or 
three weeks, filling the iliac region, and extending up to the 
ribs, and, laterally, to the median line. It was exquisitely pain- 
ful, so that it was examined with difficulty ; still, I detected a 
deep-seated fluctuation under the coecum, and my diagnosis was 
an iliac abscess, resembling somewhat those described by obstetric 
writers as occurring in puerperal women. The abscess, how- 
ever, which in these cases can generally be felt through the 
natural passages, and often breaks into one of them, could not 
be found in this case. At the end of about three weeks, after 
very serious symptoms, I detected a small, hard lump, deep in 



ILIAC TUMOR. 181 

the groin beneath Poupart's hgament, and on the outside of the 
ofreat femoral vessels, and in immediate contact with them. This 
I cut down upon with great care ; and, on opening it, a small 
stream of pus followed, which continued to flow freely two or 
three days. The symptoms were at once relieved. The con- 
valescence was, of course, slow. She ultimately entirely re- 
covered, with a better condition of health than before. 

In another case, a lady, going down a steep hill covered with 
ice, slipped ; and in trying to recover herself, the body was 
thrown violently backwards. A snap was felt, as though 
something had given away in both groins, more particularly the 
right. I did not see her until some weeks after the accident. 
She had been unable to walk, in the mean time, without great 
pain in the abdomen, and had much disturbance in the intestinal 
canal. A few days before I saw her, there was a great discharge 
of pus from the intestinal canal, attended with relief. I could 
not detect any swelling in the iliac region, although it was ex- 
cessively tender on pressure. It was nearly a year before she 
was able to bear the motion of a carriao^e, without causino- a 
recurrence of the symptoms in the abdominal and pelvic regions. 

Dr. James Jackson, in his "Letters to a Young Physician," 
mentions a tumor occurring in the iliac region, which he calls 
"a painful tumor near the coecum," by way of distinction , some- 
times of an acute, and sometimes of a chronic character, which 
I have frequently seen, before and since his paper was published. 
A painful, elastic tumor, of greater or less size, is felt in the 
region of the coecum, attended with fever, nausea, constipation, 
and a OTeat feelino^ of distention. Pelief is oained from cathar- 
tics, which, however, I have generally been sparing of, having 
trusted to rest, fomentations, and sometimes leeches. In one 
case, in which powerful purgatives had been tried for a Aveek, 
without effect, the sufferings became dreadful, and introsuscep- 
tion was feared. I advised that the patient should be placed 
under the influence of opium, and means used to reduce local 
inflammation. This being effected, evacuations took place spon- 
taneously, and the patient recovered. In one instance, I have 
seen the disease recur twice, with an interval of one or two years. 
The duration of treatment has usually been about two weeks. 



182 ABDOMEN. 

This tumor is important, as it is often not detected by a 
physician unaccustomed to it ; and I have seen a number of 
cases which have gone on a w^eek or more before the cause of the 
symptoms v^as found out. With Dr. Jackson, I have never seen 
it suppurate, though it is difficult to say exactly how it differs 
from those that do. The principal distinction seems to be that 
it is more sluggish, and its confines more definite, than in those 
tumors of the iliac region which terminate in suppuration. 



CHAPTER VI. 

ANUS. 

HEMOREHOIDS. 

The common operation for hemorrhoidal tumors, for the last 
thirty years, has been by ligature. Before that time, I have 
seen excision practised, but, I may say, almost always followed 
by troublesome, if not dangerous, hemorrhage. The ligature is 
safe and effectual. I have generally performed the operation as 
follows : — 

The bowels are cleared the day before. On the same day, 
prior to the operation, no solid food should be taken. The pa- 
tient being etherized, the tumors are extruded by the finger, and, 
one after the other, seized with hooked forceps, the base trans- 
fixed by a double ligature, and tied on each side with great 
force, and the ends cut off. The skin of the edges of the anus 
should not be impinged upon ; and, if this cannot be avoided, a 
ojroove should be made for the lio^ature with a knife. The 
tumors are then returned within the anus. The patient is kept 
very quiet in bed, avoiding opiates, if possible, and can almost 
always go for eight days without an action of the bowels, unless 
the stomach is disturbed by improper food. A mild cathartic 
may be then administered, though sometimes the bowels are 
freed spontaneously. 

The swelling which takes place sometimes causes a retention 
of flatus, which gives a sensation of great pressure. This is 
relieved by the cautious introduction of a large gum-elastic 
catheter into the rectum. Ketention of urine, requiring the use 
of the catheter for about three days, — and I have once seen it 
last eight, — is not an unfrequent occurrence. I have once or 
twice tried, successfully, the use of the ecraseur ; but, in very ex- 
treme cases, should think, unless it was very carefully managed, 
that its use might be followed by hemorrhage. 



184 ANUS. 

Case XCVII. — Hemorrhoids. Operation, Cure. — 
W. A., 42 years of age, a large, muscular man, had been 
troubled for seventeen years with external and internal hemor- 
rhoids. He was habitually constipated, and frequently, during 
the previous seven years, had lost blood when the bowels were 
evacuated, so that his pulse was weak, and he exhibited an 
anaemic condition, and was unable to work. Sometimes the rec- 
tum was prolapsed to the extent of two or three inches. 

On the 30th May, 1863, 1 operated. He was etherized ; and 
five large, hemorrhoidal tumors were drawn down, transfixed by 
double ligatures, and tied at the base. Care was taken not to 
include any of the skin. Two large external hemorrhoids were 
also cut off. On the seventh day, the ligatures came away ; 
and at the end of a fortnight the bowels were opened by 
castor oil and enema. On the 22d of June, an examination 
showed that the internal tumors were entirely removed : there 
was no pain, and no blood was passed at stool. Three more 
external piles were excised, which completed the cure. This is 
an extreme case ; and I have seldom found it necessary to in- 
terfere with the external tumors, the removal of the internal 
ones generally suflficing for a cure. 

Case XCVHI. — Hemorrhoids. Operation. Cure. — 
A man aged 47 entered the Hospital, June 16, 1863, suffering 
with hemorrhoidal tumors, and much blanched from loss of 
blood. He had had an attack of bleeding from the rectum 
thirteen years before, and another attack seven years after. 
The last five years, he had had frequent attacks, lasting two 
or three days, the tumors and mucous membrane in the vicinity 
remaining in a prolapsed condition during the paroxysms. 

On the 20th, an enema having been previously administered, 
three or four large tumors were dragged down with hooks, and 
included in ligatures ; care being taken to avoid every thing but 
mucous membrane. 

After the operation, he required an opiate. There was for 
a few days considerable difficulty in micturition. The bowels 
were kept quiet for seven or eight days, and were then emp- 
tied by means of a mild purgative. 

He was shortly discharged, entirely cured. 



HEMORRHOIDS. 185 

Case XCIX. — Hemorrhoids. Operation. Cure. — A 
woman, 27 years of age, entered the Hospital in March, 18G(3, 
in an anaemic state, and fainting, even in the supine posi- 
tion, from constant and profuse loss of blood from hemorrhoids 
of twelve years' standing, brought on by constipation of tlie 
bowels. She said that sometimes she had lost as much as half 
a pint or a pint of blood a day, for three months at a time ; 
but this, doubtless, was an exaggeration. 

Fearing to operate on her in her reduced condition, she was 
kept for about a week in a horizontal position in bed, a tannin 
injection administered daily, and nourishing food given in a con- 
centrated form, so as not to excite action of the bowels. By this 
means, the hemorrhage was almost completely checked, and she 
rapidly gained strength enough to allow an operation. At the 
end of about ten days, four or five tumors were drawn down 
and tied in the way mentioned above. 

Very little febrile action followed the operation, and the pain 
was relieved by the local application of ice. By this means, 
opiates were avoided and her appetite preserved, so that, at the 
end of three days, she was allowed to take animal food. 

On the ninth day, having some nausea, a dose of oil was 
administered, bringing away a large evacuation, without blood. 

For the first few days, there was some retention of urine, re- 
quiring the use of the catheter. She gradually recovered, tlie 
bowels being only allowed to act every third day. I saw her 
two months afterwards in good health and flesh, and with a fine 
color. She complained of some local irritation on making any 
extraordinary exertion, or standing for any length of time ; 
which she was then, for the second time, cautioned against. 

External hemorrhoids, as already stated, do not often require 
interference, generally disappearing with the removal of the 
internal affection. Where a troublesome exuberance of inte^- 
uments is left, it may be safely excised. When external 
hemorrhoids become inflamed and painful, they are generally 
dependent on a derangement of the digestive organs. If this 
is rectified, the paroxysm passes by. AMien one of tlie tumors 
becomes strangulated, so as not to retain its position within 



186 ANUS. 

the anus, relief is almost at once obtained from a puncture, 
which gives issue to a clot of blood. 



FISSURE OF THE ANUS. 

It would be difficult to find any disease attended with such 
unmitigated suffering as this apparently trivial affection. The 
symptoms are as follows : pain as of the passage of a hot iron 
through the anus, combined with a sensation as of cutting with 
a knife, sometimes attendant on the act of defecation, at others 
coming on at an interval of a few minutes or half an hour after- 
wards ; and lasting often for several hours with such severity as 
to confine the sufferer to his back, or even to his bed ; this re- 
curring day after day, and sometimes for months or years. 

Generally a slight mucous, purulent, or bloody discharge is 
voided with the feces, giving the idea to the patient and his phy- 
sician that he is laboring under fistula. With this impression, 
he often asks advice of the surgeon. On examination, by care- 
fully pulling down and separating the folds of the anus, a small 
fissure, or crack, is discovered just within the margin, and ex- 
tending inwards for an inch or more. If the disease is of long 
standing, an ulcerated surface, with elevated edges, takes the 
place of the fissure. The seat of the disease is often the centre of 
a hemorrhoidal tumor ; and, so far as my observation goes, it 
occurs twice or three times as often in women as in men. In 
nine cases out of ten, I have found it on the coccygeal side of the 
anus, on the median line, scarcely ever on the sides. Sometimes 
two fissures are found, one behind and one in front. In regard to 
treatment, I have seldom seen it yield to the vaunted astringent 
injections of rhatany, &c., as used by the French, or to emollient 
or anodyne enemata. A number of times, when the disease was 
recent, I have found it yield to a thorough cauterization with 
a stick of nitrate of silver ; but it seldom gives way under any 
treatment short of the use of the knife. The surgical operations 
which I have seen practised, many years ago, for the relief of 
this affection, were of a savage description ; comprising not only 
the incision of the stricture, but a cut through the whole sphinc- 
ter muscle, extending nearly, if not quite, to the coccyx. My 



FISSURE OF THE AXUS. 187 

ovra practice has been as follows : to have the anus well dilated, 
and the mucous membrane drawn down so as fully to expose the 
diseased surface. If there was an ulcer of lons^ standinsr, the an- 
terior part of the ulcer was seized with forceps, and the whole 
disease carefully excised from without inwards, by means ot 
scissors ; the wound, after its removal, making the centre of a 
portion of tissue, with a margin of healthy mucous membrane. 
In case there has been much spasmodic contraction of the sphinc- 
ter, which, however, is almost always dependent on the great 
irritability of the fissure, I have sometimes made a subcutaneous 
division of that muscle. In other cases, by passing the fore- 
finger into the rectum, and hooking it under the sphincter, a 
small opening is made into its sheath ; the muscular fibres are 
then exposed by bringing them out upon the finger, and di- 
vided. This plan I have also adopted with success, in opera- 
ting in cases of rupture of the perina^um : its advantage is, that 
it avoids a large wound extending into the rectum, which may 
cause deep-seated hemorrhage, and allows the blood to escape 
externally, if there should be any tendency to bleeding after the 
division. I should have stated, in speaking of the treatment, 
that in one case in which there was o^reat sufFerins^, and violent 
contraction of the sphincter, this was relieved, and the fissure 
allowed to heal, by wearing a short metallic rectal bougie, of a 
dumb-bell shape, with an aperture in the centre for the escape 
of flatus. 

Case C. — Fissure of the Anus. — A man 35 years old, 
who had been subject to hemorrhoids for a year whenever he 
had an action of the bowels, was attacked with a most acute 
pain, not only during the passage of the feces, but for an 
hour or two afterwards. He had been under constant medi- 
cal treatment, both local and general ; and, from the feces being 
occasionally streaked with blood and pus, it was supposed to 
be a case of fistula, although nothing of the kind had ever been 
discovered on examination. He was much worn down by suf- 
fering, and was entirely prevented from doing any business. On 
separating the nates forcibly, and making traction on each side 
of the anus, so as to pull down and expose the folds of the rec- 



188 ANUS. 

turn, I at once discovered the commencement of a fissm'e, just 
within the anus. The patient being made to brace himself up, 
the fissure was gradually forced down, and exposed to view 
throughout nearly its whole extent. Its whole surface was 
then thoroughly cauterized with the solid nitrate of silver, 
which application seemed like the touch of a red-hot iron. Af- 
ter the pain, which lasted for an hour or two, had subsided, a 
distinct relief was experienced. At the next evacuation, which 
occurred two days afterwards, there was absolutely no pain. 
Subsequently, in the course of a fortnight, there was a return 
of pain during defecation. A second application of the caustic 
completed the cure. 

One or two other cases of this disease, which have come un- 
der my observation, in males, have been cured under a similar 
method of treatment. 

Case CI. — Fissure of the Anus. — A lady 35 years old, 
who had suffered severely from hemorrhoids during pregnancy, 
after her last confinement (which was two years before I saw 
her) , began to have severe burning and lancinating pain after 
every operation from the bowels. Her sufiferings gradually in- 
creased^ until they became almost insupportable, and confined 
her to the bed during the greater part of the day, after each 
evacuation, which caused severe constitutional disturbance, such 
as chills and fever, with profuse sweating. Every kind of 
treatment had been tried, in the way of local applications, in- 
jections, and laxatives, together with occasional opiates, but 
without permanent benefit. As any examination with the finger 
was utterly insupportable, she was etherized, and preparation 
made for an operation if it should prove to be necessary. On 
separating the folds of the anus, a broad fissure was discovered, 
or rather ulcer, with depressed centre and elevated edges, 
which extended into the rectum for some distance. The anus 
was now drawn well open by two assistants, and the external 
portion of the ulcer firmly seized with toothed forceps, and a 
careful dissection made with pointed scissors ; the ulcer being 
gradually dragged down as the dissection progressed. In this 
way, the entire diseased surface was thoroughly excised. After 



FISSURE OF THE ANUS. 189 

the operation, no evacuation was permitted for a week : the 
first dejection w^as attended with some pain ; but, as the wound 
healed, the pain became less, and a good recovery took place. 
It is now nearly nine years since the operation, and she has been 
entirely well since. 

Case CII. — Fissure of the Anus. — About the year 
1850, I saw, in consultation with Drs. James Jackson and J. 
C. Warren, a lady, about 40 years old, who for a number of 
years had suffered from symptoms of fissure of the anus. She 
was very feeble, and in an anaimic state. There was very 
violent spasmodic contraction of the sphincter, which almost 
prevented the evacuation of the bowels. The patient being 
etherized, I was requested to operate. The fissure being of 
long standing, and much firm material effused about it, it was 
entirely excised, as in the last case. A tenotomy knife was 
then carefully worked in under the sphincter, which w^as put on 
the stretch by two fingers in the anus, and the muscle divided by 
a subcutaneous section. The patient, after the ordinary treat- 
ment, was effectually cured. 

Case CIII. — Fissure of the Ames. — Nov. 1862. A lady, 
26 years old, began about a year and a half before, and not 
long after the birth of a child, to suffer from a pain in the 
region of the rectum, after defecation. This pain she referred, 
not to the anus, but to a spot in the rectum opposite the lower 
end of the sacrum. In the course of the day, a small collec- 
tion of purulent matter would take place in the rectum, and 
the discharo'c of this was attended with most terrible suffering. 
The pains gradually extended to the sciatic and other nerves of 
the pelvis. She generally enjoyed pretty good health ; was mar- 
ried, and had one child. The catamenia were regular, and there 
was no apparent trouble about the uterus. She was seen by a 
distinguished surgeon in the army, who exhausted every avail- 
able means of relief, but to no purpose. I had no doubt, from 
the description which she gave me when I first saw her, that 
she had a fissure of the anus ; although she could not believe 
that the pain which appeared to be so high up within the rectum, 



190 ANUS. 

and the pams In the limbs, could be attributed to this cause. 
On separating the folds of the anus, an ulcerated fissure, 
opposite the coccyx, was at once manifest ; but an attempt 
to explore it with the finger was attended with such suffering 
that it was necessary to desist. I advised her to take a 
private room at the Hospital, where the operation was per- 
formed under ether. As soon as the irritability of the sphinc- 
ter was overcome by the influence of the anassthetic agent, the 
finger could be passed up into the rectum, which, so far as could 
be ascertained by the sense of touch, was in a perfectly healthy 
condition. The fissure extended from just within the margin of 
the anus into the rectum. The ulcer was of moderate depth, 
with hard and elevated edges. I firmly grasped the whole ulcer 
with toothed forceps, and dissected it out with scissors. The 
night after the operation, she was free from pain, and in fact had 
no pain for five or six days, during which time she had no evac- 
uation of the bowels. At the end of this period, she took a 
laxative ; and the evacuation which followed was attended with 
a little pain, as might have been expected while the wound re- 
mained unhealed. During the next week she did well, so far as 
regards pain about the anus ; but she had one or two severe 
attacks of sciatica, which required the use of remedies. At 
the end of a fortnight after the operation, she left the Hos- 
pital, at her own request, to go to the house of a friend, appar- 
ently well. A week later I was requested to see her, and found 
that all the old symptoms had returned. Her bowels, from the 
want of proper management, had become quite costive, the dis- 
charges taking place in hard lumps. On examination, the wound 
was found to be nearly healed, and in a healthy state : it was 
touched with nitrate of silver. This application, conjoined with 
a laxative diet, gave relief for several days, when it had to be 
repeated. At this time she was compelled, by the illness of her 
husband, to return home. 

In March, 1863, she came again to Boston, having a recur- 
rence of all her troubles, with all their former severity. I 
advised her again to enter the Hospital, and to stay there until 
cured, if possible. She was etherized, and a crack was found 
in the same place as before, but not strictly in an ulcerated 



FISTULA IN ANO. 191 

condition. A cut was now made directly through it, and about 
a third part of the thickness of the fibres of the external 
sphincter included in the incision. This operation again af- 
forded relief for a week or ten days, when the attacks of pain 
began to return at irregular intervals, often in the middle of the 
night, and assumed a violently hysterical character. Cauteri- 
zation again gave partial relief. During this time the catamenia 
had been irregular, the discharge taking place three days every 
week. 

She was kept under treatment for her general health, and 
soon entirely recovered. I saw her a long time afterwards, 
without any recurrence of her former troubles. 

This case is important, showing how necessary it is to perse- 
vere in treatment, where the mind of the surgeon is confident of 
the cause of the symptoms. Here it was necessary to work 
constantly against the persuasions of the patient, who persisted 
that her sufferino-s had some other orio;in. This idea was still 
farther confirmed, when she did not get complete relief by a 
single operation. 

FISTULA IN ANO. 

The operation for fistula in ano is so common, and the treat- 
ment so settled, that it is scarcely worth while dwelling on. 
I would simply say, that, in those cases of fistula, running fixr 
up into the rectum, it is unnecessary to follow the internal 
cul-de-sac to its termination, which is often a bloody and dan- 
gerous proceeding. Generally, the incision should comprise 
that portion which is included between the openings of the fis- 
tula on the rectum and outside. The internal aperture of the 
fistula I have almost invariably found just within the anus, and 
more commonly on the anterior than the posterior side. The 
treatment of injections, as used by empirics, is generally inef- 
fectual, and not only involves the loss of much valuable time, 
but gives much discomfort to the patient. 

In regard to the rule for operating on phthisical patients, I 
should say, that, if the fistula causes no irritation, avoid inter- 
ference. If much inflammation, with numerous external fistulous 



192 ANUS. 

openings, is present, causing great suffering, preventing exercise, 
and deranging the system generally, an operation often restores 
almost new life to the patient. 

Case CIV. — Fistulous Opening near the Koot of 
THE Coccyx, in the Median Line between the Nates ; 
THE Fistula containing Hair. — The following case was 
presented for consultation ; and is similar to those which I have 
frequently had under observation, but have nowhere seen des- 
cribed. The mode of its origin has not yet been clearly made out. 

Jan. 1864. — A young man, 25 years of age, with very full 
development of hair on the body, applied to me on account of 
a small fistulous opening, which he had upon the sacrum, just 
between the folds of the nates. The first intimation which he 
had of it was from the exudation of moisture from this spot 
about one year ago. At first the discharge was thin, but after- 
wards assumed a purulent character. Recently the disease be- 
came more serious, and the soreness and inconvenience resulting 
from the discharge led him to seek medical aid. On examina- 
tion, a small circular opening was seen, just large enough easily 
to admit a probe, looking as if the skin had become inverted at 
that point, and quite unlike the ragged, inflamed orifice of a com- 
mon fistula. A sero-purulent matter oozed out from the interior. 
The probe penetrated upwards between one and two inches. I 
at once recognized an aflPection which I had frequently observed. 
On opening this fistula in similar cases, a small curl of hair has 
generally been found occupying the bottom of the cul-de-sac. 
This hair seems occasionally to act as a foreign body, giving rise 
to inflammation, with the formation of abscess, resulting in 
fistulous openings extending in various directions, thus often 
concealing the original difficulty. By a careful exploratory op- 
eration, however, the little wisp of hair may be discovered in 
some part of the sinus, lying perfectly loose, and unattached to 
the surrounding tissues. I have once seen this in a woman 
whose hair was dark, and more than usually developed in that 
region : all the other cases, numbering perhaps eight or ten, 
have been in men. 

The origin of this singular aflPection is involved in obscurity. 



FISTULOUS OPENING NEAR COCCYX. 193 

It would seem possible, however, that it may begin in the stout 
hair or hairs arisin": from a sino'le follicle becomino' in some 
way diverted from their normal direction, and inverted upon 
themselves within the follicle itself: the continued growth of 
the hair would then result in the formation of a tangled knot or 
ball of hair, which might readily give rise, after a time, to irri- 
tation, just as a similar accumulation of sebaceous matter in the 
follicles of the face may excite that form of inflammatory action 
known as acne. The occurrence of the disease in the median 
line between the folds of the nates may perhaps be explained by 
the constant pressure and moisture of the part, softening both 
the newly formed hair and the epidermic cells surrounding the 
mouth of the follicle. 

The treatment of this affection consists in laying freely open 
the cavity or cavities where the occurrence of inflammation has 
involved the skin and subcutaneous tissue ; or, in case the skin 
still remains healthy, the sac may be laid open and then dis- 
sected out. The integuments should be brought together with 
one or two sutures, thus insuring a more speedy cure than if a 
simple incision is practised. 

This affection is interesting, in connection with what has just 
preceded it, from the fact that the persons who apply for relief 
almost always suppose that they are laboring under the disease 
of fistula in ano. 

Case CV. — Fistulous Opening in the JSfeighhorhood of 
the Anus, containing Hair, — A man entered the Hospital, 
July 31, 1866, to be operated on for what he supposed to be 
fistula in ano. He had received a kick on the nates a year be- 
fore ; and a small, hard lump had been left, which had recently 
suppurated. There was an opening near the anus, and an- 
other near the coccyx, neither of which communicated with the 
rectum. A director passed freely from one to the other. 

On laying the whole track of it freely open, a tuft of hair 
was found between the two openings, quite free, and entirely 
devoid of bulbs. The patient left the Hospital in about a 
week, in a fair way for recovery. 

25 



194 ANUS. 



PKOLAPSUS ANI. 



The disease which goes by this name — and it is usually con- 
founded with an eversion of the mucous membrane, attendant 
on extreme cases of internal hemorrhoids — is a very rare affec- 
tion. The patients in my practice, in whom the whole calibre 
of the intestine prolapsed at each evacuation of the bowels, 
have generally been children of a scrofulous habit, who have 
suffered from obstinate constipation, from irregularity of the 
bowels, from dysentery, or from ascarides of the rectum. The 
disease has almost always yielded to an invigorating course of 
treatment with iron, a nourishing diet, which leaves but a little 
residue, and astringent injections. Before an evacuation, an 
enema of cold water or a solution of tannin was adminis- 
tered. I have also seen it in old persons, and in persons 
suffering from stone in the bladder, where the straining is 
extreme. 

The records of the Massachusetts General Hospital give the 
following numbers, for a period of forty years ; and probably 
one-half of these are misplaced, being cases of everted hemor- 
rhoids : — 

Total number of cases 19 

Cured 11 

Much relieved 4 

Relieved . 4 

The treatment generally seems to have been by ligatures 
applied to portions of the mucous membrane around the anus, 
as for hemorrhoids. The following case I treated by cauter- 
ization with acid nitrate of mercury. 

Case CVI. — Prolapsus Ani. Cauterization. Cure. — 
A boy, aged 14, of English birth, entered the Hospital May 
20, 1858. He said that he had a prolapsus when only two 
years old, which disappeared, and returned eight years after. 
The whole calibre of the rectum was forced down for one or two 
inches during every act of defecation. 



POLYPUS OF THE RECTmi. 195 

The boy being etherized, the intestine was everted, and a 
ring of it cauterized with the acid mentioned above. The pro- 
lapsus was then reduced. The bowels were kept quiet for a 
number of days, but no recurrence of the prolapse occurred 
when they acted. He was kept under observation until it was 
certain that the cure was complete. 

Where prolapsus is complicated with hemorrhoids, the treat- 
ment which relieves the latter will also relieve the former ; i.e., 
the ligature or ecraseur. 

POLYPUS OF THE RECTUIM. 

Polypus of the rectum is a very rare affection, and usually 
of mild character. I do not remember having seen more than 
^ve or six cases of it. The first of the following, operated on 
by myself, is the only one recorded on the books of the Hos- 
pital up to 1860 : — 

Case CVH. — Poly pics of Rectum. Removal. Cure. — 
March 21, 1860, a boy, nine years of age, entered the Hospital, 
for a vascular tumor, which occasionally projected through the 
sphincter ani, it having been first discovered four years before. 
It gave him great discomfort. With the finger, I could dis- 
tinguish it about two inches above the sphincter, of the size of a 
chestnut, attached by a broad base to the intestinal w^alls. 

The patient being etherized, the tumor was dragged down 
outside, and removed by the dcraseur. He was discharged well, 
on the 26th. 

Case CYIII. — Polypus of Rectum., — -A gentleman, who 
had once or twice suffered from fissure of the anus, consulted me 
about a tumor which occasionally came down while the bowels 
were being evacuated, and became pinched by the sphincter. 
By a digital examination, a hard tumor, the size of a small 
walnut, was found hanging to the parietes of the rectum by a 
narrow stalk, about two inches from the external orifice. I ad- 
vised its removal by twisting, or with scissors. His mind, how- 
ever, being relieved as to the character of it, and being much 
occupied, the operation was deferred, and I heard nothing farther 
from him in regard to the tumor. 



196 ANUS. 

A year after, having fissure of the anus, which was operated 
upon, it was found that the tumor had disappeared. In all 
probability, it had been twisted off and discharged by the action 
of the bowels. 

Case CIX. — Polypi of the JRectiim. Fissure of Anus. 
Operation, Cure. — In April, 1866, I was requested to 
operate on a lady who had been suffering for a number of years 
from a bad fissure of the anus, which, on examination by her phy- 
sician, was found to be complicated with polypoid tumors of the 
rectum. The fissure, which was found to be in a very diseased 
and thickened state from long ulceration, was dissected out with 
the scissors. Three or four polypoid tumors were then hooked 
down from the rectum, and either cut off, or tied, where the 
vascularity seemed unusual. She had a slow recovery ; but I 
heard of her two months afterwards in fine health and spirits. 

Case CX. — Polypus of Rectum. Removal. — A woman, 
about 35 years of age, very nervous and delicate, who had re- 
ceived much treatment without avail, entered the Hospital in 
April, 1866, — the same week that I operated on the last case. 
The functions were generally deranged, and there was scarcely 
an organ in the body which was not complained of. She re- 
mained, for the most part, in bed, saying that she was too feeble 
to sit up, and attributed her troubles mainly to a tumor in the 
rectum. 

On examination, a tumor was discovered similar to those de- 
scribed above. It was dragged down and tied ; the ligature 
coming away about the fourth day after the operation, 



IMPERFOEATE ANUS AND RECTUM. 

It may not be considered inappropriate here to introduce the 
subject of malformation of the anus and rectum, which is one 
of great interest, as involving the question of operation and 
the life of the patient. 

The following cases of imperforate anus, with malformation 
of the rectum, present several points of interest in connection 



IMPERFORATE ANUS AND RECTUM. 197 

with the question of attempting to afford relief by a surgical 
operation. In simple occlusion of the anus, there can be no 
doubt of the propriety of opening it, either by puncture or 
crucial incision, maintaining the passage afterwards by the 
use of bougies. The great majority of cases, however, as 
they occur in practice, are by no means so easily disposed of; 
being, as a general rule, complicated with an imperforate con- 
dition of the lower part of the rectum, and, in many instances, 
also with an abnormal opening communicating either with the 
external surface of the body, or more commonly with the blad- 
der or vagina. In a very considerable proportion, also, the 
anus is perfectly formed externally, but terminates within in a 
cul-de-sac ; and a few instances have been recorded in which 
there was a total absence of the rectum, and even of the whole 
large intestine. Of this latter malformation I have seen one 
case, in which the large intestine was absent, with the exception 
of the coecum ; and the specimen has been preserved. 

Upon the subject of operating for the relief of imperforate 
rectum, surgeons are by no means unanimous. The great 
fatality which attends these operations ; the difficulty often ex- 
perienced, in the after-treatment, to prevent the closure of the 
artificial opening ; and lastly, and perhaps chiefly, the very 
imperfect character of many of the so-called cures, resulting in 
life-long discomfort to the patient, — have induced many sur- 
geons of experience altogether to discountenance operative inter- 
ference. On the other hand, the certainty of death, if left to 
nature ; the fact that the operation has sometimes been fully 
successful ; the promise afforded by improved operative methods ; 
and, finally, the natural reluctance of the surgeon and friends 
to leave any thing untried which may possibly save life, — 
combine to justify any rational attempt at relief. The theory 
that the results are necessarily imperfect, which affords the only 
real argument against operating, is disproved by the very suc- 
cessful cases recorded by Benjamin Bell, Amussat, Latta, and 
others. 

The operation which promises the best results, and which I 
have several times performed with success, consists in freely 
dissecting throuo;h the tissues which intervene between the cul- 



198 ANUS. 

de-sac of the rectum and the external surface of the body, then 
drawing down and puncturing the bowel, and finally securing it 
by sutures to the margins of the divided integument ; thus 
formino^ a new canal with a continuous mucous linins:, instead 
of the long fistulous passage which results from a mere punct- 
ure with the bistoury or trocar. 

During the year ending June, 1864, I saw four cases of 
imperforate anus and rectum. In two of them there was a 
fistulous passage, communicating in one case with the vagina, 
and, in the other, opening in the perineum half an inch in front 
of the normal position of the anus. In both of these cases, I 
was able to re-establish the natural passage by the operation 
just described. In a third case, upon which I operated by 
puncturing the distended rectum, the child died ; and, in a 
fourth case, I advised against any operative interference. These 
four cases I propose to relate. 

Case CXI. — Imperforate Amis, with Ahnormal Open- 
ing of the Rectum externally. Operation. Cure. — A female 
child was born with a small fistulous opening directly be- 
hind the vagina, and half an inch in front of the normal 
position of the anus, through which the fecal matter was dis- 
charged very slowly and with much difficulty. The child was 
therefore brought to the Hospital, where the opening was en- 
larged by one of the surgeons, who enjoined upon the parents 
to keep it from closing up again by the daily employment of 
tents. In spite, however, of the attention which was given 
it, the aperture became gradually contracted, so as to cause 
much distress whenever the bowels were evacuated, and to 
lead the parents to bring the child again for operation, in the 
spring of 1863, when it was about two years old. The 
operation was performed by passing a curved instrument into 
the fistulous opening, turning it backwards, and pressing the 
intestine down upon its point where the sphincter-ani muscle 
should naturally be situated. Here a dissection was made until 
the sound was exposed, and the intestine freely opened by a 
crucial incision. The intestine was now attached, by two or 
three points of suture, to the skin, and a tent passed into the 



IMPERFORATE ANUS AND RECTUM. 199 

opening. The child bore the operation well. After a few 
days, the tent was removed ; and the daily use of bougies, 
gradually increasing in size, was commenced. By the end of 
the third week, it became difficult to introduce the bougie, 
owing to the very powerful resistance offered by the sphincter 
muscle : this, however, always yielded to pressure, and the re- 
moval of the bougie was followed by a free discharge of fecal 
matter. At the end of a month, the child left the Hospital ; the 
mother being requested to bring her twice a week in order to 
have the bougie passed, and the abnormal opening cauterized 
for the purpose of closing it. Three months afterwards, the 
case was lost sight of, a small fistulous opening still remaining, 
through which there was occasionally a slight discharge ; the 
new anus performing its functions perfectly. 

Case CXII. — Imperforate Anus, toith Rectum opening 
into the Vagina. Operation. Relief. Death from Gas- 
tric Irritation two months after. Malposition of Intestine. 
— In June 1863, a fine, healthy girl, six weeks old, was brought 
to me, with the rectum terminatino' in the vas^ina. An incision 
had been made by the attending physician, at the point where the 
anus would be naturally situated ; but he had not succeeded in 
establishing the passage. On account of the very early age of 
the child and the small size of the organs, it was very difficult to 
determine the exact condition of the parts. The mother said that 
the child was perfectly well, except that the discharges took place 
through the vagina. A probe passed into the vagina entered 
about two inches : in front of this, another probe could be passed 
into the urethra, these two passages being entirely distinct. 
After considerable manipulation, it was found that the whole 
posterior wall of the vagina, and the adjoining anterior wall 
of the rectum, were wanting. The o[)eration for the restora- 
tion of the natural passage was done as follows : A large silver 
hook, with a ball at the end, was passed into the vagina, and 
forced down against the spot at which it was proposed to 
make the new opening. Here it could be indistinctly felt through 
the thick mass of the soft parts which intervened. A crucial 
incision was made through tlie skin, and the soft parts dissected 



200 ANUS. 

to either side, until the silver ball, pressing down the intestine, 
was felt in tlie wound, the wall of the intestine only inter- 
vening. A small aperture was now made in the gut, and the 
hook passed through so as to hold the parts in position. The 
opening in the intestine was then enlarged, and its margin 
stitched to the integument by four sutures. A plug was then 
introduced into the opening to the depth of an inch and a half or 
two inches. After the operation, a free discharge took place 
from the vagina, showing that the plug would not interfere with 
the passage of the feces while the new anus was being estab- 
lished. 

A large and well-formed canal was established in the normal 
position, through which well-formed, solid discharges took place, 
from time to time, while the more liquid feces still made their 
way through the vagina. The child was too young and the 
vagina too inaccessible for any attempt to be made to close the 
abnormal passage : this it was proposed to do at a later period. 
For a while, the child enjoyed perfect health ; but subsequently 
was attacked with gastric irritation, and died Aug. 4, 1864. 

The following extracts from a letter from Dr. Cox, of Salem, 
the attending physician, give an account of the post-7nortem 
appearances : — 

" On Tuesday, the 2d, I first saw her. She had constant nausea, 
and vomited almost every thing she took into her stomach, and had no 
alvine discharges. These symptoms continued, more or less urgently, 
till her death, on the 4th, except that the bowels were slightly moved 
several times. Independently of the state of the atmosphere of late, 
this condition was perhaps remotely caused by a malformation and 
transposition of the large intestine, in consequence of which a free and 
thorough evacuation of the organ seldom, if ever, took place. . . . 
The rectum ascended from the anus to the right iliac fossa, thence up 
through the right lumbar region to the under surface of the liver, 
touching the gall-bladder. Then it bent sharply downwards, and de- 
scended, in contact and parallel with the ascending portion, to the right 
iliac fossa. The colon then crossed the lower part of the abdomen to 
the left iliac region, up through the left lumbar region, almost to the 
stomach, terminating in the coecum. . . . The portion discolored with bile, 
from its contact with the liver, is where the sudden and abrupt bend of 
the organ downwards took place. This sharp flexure must have proved 



OIPERFOKATE ANUS AND RECTUM. 201 

a serious obstruction to the evacuation of the bowel. From this turn to 
the caput coli, the bowel was very much distended with flatus, and con- 
tained more than a quart of soft fecal matter of the consistency of 
thin mortar. The only other morbid change found was an injected and 
softened state of the mucous coat of the stomach." 

An incision being made in the back part of the rectum, near 
the anus, displayed a very great contraction of that canal just 
before its oris^inal termination in the vaccina. In fact, folio win 2^ 
this contraction was a cul-de-sac ^vhich communicated with 
the vagina, about its middle, by a delicate valvular opening ; the 
artificial anus continued the intestine down to its natural exter- 
nal termination. It will be understood, therefore, that, instead 
of a free communication between the intestine and vagina, there 
was a plaited condition of the mucous membrane, as in the 
ordinary termination of the canal. 

The descending colon in this, as in another published case, 
was transposed ; so that any operation for artificial anus, as 
usually practised in the left lumbar region, would necessarily 
have failed of its object. I would advert to the very interesting 
fact, exemplified in the present case, and to which attention has 
many years since been called by Dr. J. B. S. Jackson; viz., 
the very constant termination of the intestine in the vagina in 
cases of imperforate anus in the female. Dr. Jackson has also 
remarked, that, in all the cases of simple imperforate anus that he 
has examined in the male subject, a small opening has been 
found between the rectum and the membranous portion of the 
urethra ; and this opening in the male he regards as analogous 
to the one above referred to in the female. This is well depicted 
in Plate X. of Dr. William Bodenhamer's valuable w^ork enti- 
tled, "Congenital Malformations of the Rectum and Anus." 

Case CXIII. — Imperforate Rectum, Operation. Death, 
— April 9, 1864. A very small child, three days old, which 
had not yet nursed, was brought to me with the rectum imper- 
forate about three quarters of an inch above the anus. Though 
the child was quiescent, the abdomen w^as distended almost to 
bursting. A finger, being introduced into the anus, encountered 
the obstruction ; but there appeared to be no rounding out of the 

26 



202 ANUS. 

septum, indicating the continuance of the canal above. It was, 
however, decided to make an exploratory puncture with the 
trocar. When the instrument was thrust in, the meconium 
began slowly to flow out, until at least half a pint had escaped, 
and, pressure being made upon the abdomen, flatus followed. 
The finger was then passed up above the obstruction, so as to 
freely dilate it. No large cavity or depot of the fluid could be 
detected. It was advised that the finger should be passed up 
once or twice a day, which the medical attendant promised to 
do, and also to report the course of the case. 

The child took food immediately after the operation, and, for 
a time, seemed relieved. It died, however, the same night, 
about twelve hours after the operation. At the autopsy, a 
quantity of blood was found in the abdominal cavity, but no 
meconium. A fibrous cord about an inch long intervened be- 
tween the rectum below and the eul-de-sac of the imperforate 
intestine above. The great distention of the intestine by me- 
conium had forced it down into the pelvis, bringing it in contact 
with the bottom of the anal cavity. On thrusting in the trocar, 
the intestinal contents freely escaped ; but, on the withdrawal 
of the canula, the upper portion of intestine retracted, and the 
aperture in it closed so as to be with difficulty distinguished. 
The oozing of blood into the abdominal cavity probably took 
place from the lower aperture. The very unusual state of the 
parts disclosed by the autopsy showed that no operation could 
have been of service. 

Case CXIV. — Imperforate Rectum, — May 12, 1864. 
A female child, not quite 24 hours old, was brought to me 
with imperforate rectum. The abdomen was quite distended, 
vagina and anus natural ; the little finger could be passed half 
an inch within the anus, when it was suddenly arrested. When 
the child strained, a sensation was felt of something pressing 
down on the finger ; but it did not convey the impression of a 
portion of intestine distended with fluid. On passing the little 
finger of the other hand into the vagina, the uterus could be 
distinctly felt as in its natural position. The finger could then 
be passed over the finger in the anus against the spine, but 



nUPEKFORATE ANUS AND RECTUM. 203 

detected no tumor ; nor could any appearance of distended in- 
testine be distinguished elsewhere, although the finger could be 
turned round and felt through the parietes of the abdomen. A 
probe was passed a little way into the urethra, but did not pene- 
trate the bladder, although urine, thick and apparently semi- 
purulent, was discharged when the examination commenced. 
It was thought possible, but not j)robable, that the intestine 
might communicate with the bladder. Under the circumstances, 
no operation was advised. Dr. D. W. Cheever, who had ex- 
amined the patient the day before, had already given the same 
opinion. 

The child lived nine days, taking little or no nourishment, 
the abdomen becoming gradually more and more distended. On 
post-mo7'te7n examination, the intestine was found to terminate 
in a cul-de-sac between one and two inches above the imper- 
forate anus : the sigmoid flexure, instead of being in its proper 
place, was found transposed to the right iliac region, where it 
lay in contact with the right side of the vagina, from which 
it could readily have been reached and punctured. A probe 
was easily passed to the fundus of the uterus, the os and cer- 
vix being very large. I was surprised to find with what ease 
the little finger could be passed without violence to the very 
bottom of the vagina, a fact which may be of material impor- 
tance in elucidating some of these very obscure cases. 

The specimens of this and the previous case are now in my 
private collection. 



CHAPTEE VII. 
GENITO-UEINARY OEGANS. 

STONE IN THE BLADDER. 

Since the introduction of lithotrity and the use of ether, the 
operation for stone in the bladder has undergone a very great 
amelioration ; and, though once considered of a most formidable 
nature, it is now, in many cases, almost stripped of its terrors. 

While in Europe, through the politeness of Sir Astley 
Cooper, I had an opportunity of seeing some of the earliest 
instances of lithotrity performed by the improved stone-breaking 
instruments of Heurteloup ; and afterwards, having witnessed the 
unparalleled skill of Civdale in breaking the stone, and having 
followed the lessons of Amussat, I was early led to adopt litho- 
trity instead of lithotomy. I pursued this practice, though not 
to the entire exclusion of lithotomy, for about thirty years, with- 
out the loss of a single life. During the spring of 1866, how- 
ever, I lost two patients : both of them died after a single 
operation of the mildest character ; and an investigation showed 
that death would have resulted, whatever course might have been 
adopted. 

The cases in which it may be well to employ lithotomy are, 
in the first place, children ; secondly, persons with large and 
hard stones, or with organic changes in the bladder or prostate. 
I have, however, frequently relieved old persons, even where 
the prostate has been considerably enlarged, by repeated, but 
not prolonged, lithotritic operations. 

The success of lithotrity, so far as my own observation goes, 
depends upon the following circumstances : 1st, To inject the 
bladder moderately with water ; 2d, To use an instrument of 
moderate size, and so constructed as thoroughly to clear itself 
of the fragments ; 3d, Not to move the instrument about too 



STONE IN THE BLADDER. 205 

freely. By not observing this last precaution, inflammation 
may be excited, and even gangrene and death ensue. By at 
once gently sinking the beak of the instrument into the most 
dependent part of the bladder, opening and giving it a slight 
oscillating movement, the stone will, in almost every instance, 
fall readily into its grasp, and may then be raised into the middle 
of the cavity, and broken. The same process may be repeated 
upon one or two of the larger fragments, taking care, however, 
not to protract the operation beyond a few minutes. A large 
catheter may then be introduced, and some of the finer particles 
allowed to escape through it. Usually two or three days elapse 
before the bladder recovers sufficient tone to expel the fragments 
spontaneously. 

In old persons, in whom the prostate is more or less en- 
larged, the stone is often concealed in a cavity behind it, and 
requires that the beak of the instrument should be turned back- 
w^ards, and the stone pushed out from its lodging-place, before it 
can be properly seized. 

Ether is a most valuable adjuvant in a great proportion of 
cases of lithotrity. When I first urged its employment in this 
operation, in a paper published in "The American Journal of the 
Medical Sciences," in 1848, many surgeons objected (and some 
still object) to its use, upon the ground that the consciousness 
of the patient is necessary to give warning if the folds of the 
bladder become entangled in the jaws of the instrument. In 
answer to this objection, it may be stated, that the mere contact 
of the instrument, in an irritated state of the organ, will give 
rise to greater suffering than the actual engagement of the mu- 
cous membrane in other cases ; and, to a surgeon at all in the 
habit of performing this operation, the interposition of a fold of 
soft tissue is at once perceptible, although I have never known 
any unusual pain manifested from this circumstance. In cases 
of extreme irritability of the bladder during an advanced stage 
of the disease, where there is an entire want of power to retain 
the urine, I have been astonished at the great quantity of ether 
which is required to produce perfect relaxation, so as to admit 
of the injection of the small amount of water necessary to pre- 
pare it for the subsequent manipulations. 



206 GENITO-URINARY ORGANS. 

In regard to the method to be preferred in lithotomy, I have 
generally adopted, until lately, that of Dupuytren, by the bi- 
lateral incision. This is still a favorite with some French and 
many American surgeons. Its chief peculiarity consists, as is 
well known, in the transverse incision of the skin, which is 
made directly in front of the anus ; and, secondly, in the double 
division of the prostate by the lithotome cachS. 

The absence of important nerves and vessels in the median 
raphe affords a strong argument in favor of the median over the 
common lateral incision ; and the revival of perineal section 
by Mr. Syme has demonstrated the fact that the bladder may 
be safely and easily reached in this manner. Influenced by 
these considerations, I have several times operated by a median 
incision in the raph^, dividing the prostate with the double litho- 
tome or with a bistoury. The advantage of this method over 
the transverse incision of Dupuytren is the greater room which 
it affords for the withdrawal of the stone through the external 
wound, while all its peculiar advantages are secured by the 
double incision of the prostate. 

Lithotomy, notwithstanding the extraordinary success said to 
have been attained in certain sections of our own country, is 
nevertheless, in town and hospital practice, an operation at- 
tended with considerable risk. 

The operations for stone, in New England, may be said to 
be very rare, but in the limestone regions of the South and 
West are quite common. Dr. J. C. Warren, in a paper pub- 
lished in 1844, stated, that, in the course of forty years, he had 
been called on to perform all the operations for stone which had 
been done in Boston. The whole number had not exceeded 
twenty-five cases, and the population had increased during this 
time from twenty-six thousand to upwards of a hundred thou- 
sand. Of the twenty-five cases, not more than three were in 
persons natives of Boston or vicinity. During the succeeding 
ten years, from 1844 to 1854, he operated for stone quite a 
number of times. In the course of about ninety years one hun- 
dred cases were operated on by Dr. John Warren, John C. 
Warren, and myself, and the specimens are in my possession. 
In the last thirty years, I have operated on rather more than 



STONE IN THE BLxVDDER. 207 

thirty cases ; and the operation has also been performed by other 
surgeons. Most of these cases were from a distance, but four 
or five of them belonging to Boston. Two-thirds of them were 
operated on by lithotrity. 

The following cases are selected as illustrating some particular 
features either in the history or the operation : — 

Case CXV. — Vesical Calculus from the Introduction of 
a Bit of Sealing-wax. Spasm of Bladder, relieved by 
Opium. Repeated Operations. Recovery. — A man, 24 
years old, entered the Hospital April 11, 1846, who, four months 
before, employed a piece of sealing-wax to remove a supposed 
stricture in the urethra. A portion about an inch long, and a 
fourth of an inch in diameter, slipped into the bladder. Soon 
after, he began to have symptoms indicating the presence of a 
stone. 

With the straight sound, in the bladder I readily detected the 
calculus; and, passing the finger into the rectum, reached it 
without much difficulty. It appeared to be on the right side of 
the bladder. 

April 12th. The patient being properly prepared, water was 
injected into the bladder ; the lithotrite was introduced, and the 
stone seized and crushed. The water was then permitted to 
escape from the bladder, bringing with it pieces of the calculus. 
The bladder was allowed to rest for four days. 

On the 16th, and subsequently several times during the 
month, the operation was repeated. At length, however, the 
presence of the lithotrite caused spasm of the bladder, which 
grasped the instrument so firmly as to interfere with its free use. 
The patient suffered so much from these trials, that he requested 
the operation of lithotomy. At a consultation, in consequence of 
this request, I introduced a very large, long staff*, such as I pro- 
posed to employ in the operation, when, to my surprise, no 
spasm occurred. 

On May 2d, all the preparations were made for lithotomy 
and lithotrity ; and the patient took a hundred and fifty drops 
of the tincture of opium, an hour before the time fixed for the 
operation. The bladder was injected with half a pint of warm 



208 GENITO-UKINARY OEGANS. 

water ; the lithotrite was introduced, no spasm occurred ; the 
operation was performed ; and, in a quarter of an hour, about 
a teaspoonful of fragments was discharged. He suffered no 
inconvenience from the tincture of opium. 

A consideration which had influence in leading me to fall in 
with the patient's wish for a cutting operation was this : in 
three instances, after repeated operations of lithotrity, the stone 
has appeared to become sacculated ; owing, I suppose, to 
inflammation of the mucous coat of the bladder. Being appre- 
hensive, from the difficulty of discovering the remaining frag- 
ment, that this process was going on, I wished to prevent its 
completion. 

He experienced so much relief from the use of the opium, that 
I resolved to try its effect when injected into the bladder. Two 
drachms of the tincture were therefore injected, on May 4th, 
with half a pint of warm water : from this he found much ease. 
On May 6th, I injected two drachms of the tincture of opium, 
mixed with two ounces of warm water, at 9^^ A.M. In an hour 
and a half afterwards, I injected as much water as the bladder 
would receive, not exceeding a gill and a half, and then intro- 
duced the lithotrite without much pain. The fragment not 
being felt, an additional pillow was placed under the pelvis. 
It was then discovered in the upper part of the bladder, seized 
twice, and broken. No great pain was experienced, and a dis- 
charge of about a teaspoonful of broken calculus took place 
soon after. 

He afterwards submitted to several similar operations, expe- 
riencing no inconvenience ; and, by June 20th, was relieved, 
and a week later was discharged. 

Remarlcs. — The stone in this case was very soft, and al- 
ways broken with great ease. There was never any lodgment 
of it in the urethra, and only on one or two occasions any 
difficulty in withdrawing the lithotrite charged, through the 
meatus. A peculiarity in the management of this case was, 
that, after the apparent introduction of the instrument, the stone 
was not reached until the handle was carried downwards towards 
the perineum, forming an angle of 45° with a line perpendicular 
to the body in a horizontal posture. From this I concluded 



STONE IN THE BLADDER. 209 

that the anterior part of the bladder had become contracted ; 
or else that the stone had formed for itself a pouch between fas- 
ciculi of the bladder, an occurrence which I think frequently 
takes place during the lithotritic treatment. The introduction 
of water as a preliminary step always brought on pain, and ren- 
dered the patient somewhat unmanageable. Occasionally, the 
water was omitted, and the operation was performed with less 
pain and in less time than usual ; while there was no reason to 
believe, that, under any circumstances, the mucous coat of the 
bladder was included between the jaws of the instrument. 
After the stone was removed, the irritability of the bladder 
was at once diminished, so that the patient, who before was 
very sensitive to the slightest motion of the instrument, allowed 
the bladder to be explored in every direction, almost without 
shrinking. The physical sensibility of the patient was much 
increased by the fear of being cut. This case illustrates the 
great advantage we have since derived from ether in overcom- 
ing the contractions of the bladder. 

Case CXVI. — Calculus of Oxalate of Lime. Stricture, 
Lithotrity under Ether. Purulent Absorption. Recovery. 
— A man 20 years of age entered the Hospital, November, 
1847, having suffered with urinary difficulties for nine years : 
eighteen months before entrance, he contracted a venereal affec- 
tion, which left him with an urethral discharge. On exami- 
nation, the urethra was found to be so contracted as hardly to 
admit the smallest sized bougie. The stricture was gradually 
dilated by the introduction of bougies increasing in size ; but, 
notwithstanding the enlarged passage and the free egress of the 
urine, he complained of much pain at the extremity of the 
urethra, and was obliged to pass his water ten or twelve times 
in the twenty-four hours. 

In March, 1848, he came under my care. Suspecting the 
existence of some foreign substance in the bladder, and the 
urethra being extremely sensitive, I placed him under the influ- 
ence of ether, and, introducing a sound, detected a stone. 

Having waited a few days to allow the bladder to recover fi'om 
the effects of sounding, on March 11th the operation of lithotrity 

27 



210 GENITO-URINARY ORGANS. 

was done. The patient was first etherized, so that the muscular 
system was in a state of complete relaxation ; half a pint of 
warm water was then injected into the bladder. A small litho- 
trite was introduced, and the stone seized ; but it proved to be 
too hard. A larger and more powerful instrument was substi- 
tuted, by which the stone was broken with repeated strokes 
from the hammer. Some difficulty was found, on withdraw- 
ing the instrument, in passing the seat of the stricture, on 
account of its jaws being clogged with sand, and therefore 
imperfectly closed. The patient was entirely insensible during 
the whole operation, and not the slightest contraction of the 
bladder impeded the necessary manipulation. 

The continuation of this history, as derived from the Hospital 
records, is in substance as follows : — 

In an hour after the operation, he passed urine, with several 
pieces of gravel, and some fine sand, in all nearly half a tea- 
spoonful. The urine contained a little blood, which was appar- 
ently from the urethra. In the afternoon, he had a severe 
rigor, lasting fifteen minutes ; passed urine once, a quantity of 
gravel coming away with it ; some small pieces of the gravel, 
which had lodged in the urethra, were removed with the for- 
ceps. The bladder was washed out with cold water : cold 
compresses were also applied to the urethra, from which a little 
blood had been oozing. In the night, he complained of head- 
ache, pulse full and hard. He was bled to 12 oz. with much 
relief; slept well. 

March 12th. — Morning. Comfortable; pulse 96. Some 
small fragments came away. Afternoon. Pulse 140 ; head- 
ache, no tenderness of bowels, and but little irritability of ure- 
thra ; passage of urine free. 

13th. The smarting and pain were very slight ; but little 
detritus in the urine. Twelve leeches to perinasum, with a 
warm bath and enema, were ordered. In the afternoon, had a 
chill; complained of malaise, pain in the shoulders, back of the 
neck, and weakness of the right arm ; pulse 130. 

16th. Pulse 120. The countenance somewhat depressed. 
Complained of great pain in the right shoulder and arm, as 
well as between the shoulders ; also in loins and left side of 



STONE IN THE BLADDER. 211 

back ; tenderness along the course of the left carotid artery ; 
no trouble in passing urine, and but little soreness of the 
urethra. 

From the 17th to the 2 2d, the febrile symptoms continued, 
the pulse being somewhat over 200, perfectly distinct and reg- 
ular. The patient being very feeble, a stimulating treatment 
was pursued. 

2 2d. I opened an abscess over the tarso-metatarsal articu- 
lation of the left little toe, and found the bone denuded. 

23d. Pulse 190. From this period the frequency of the 
pulse began to diminish, and he went on slowly improving until 
April 2d, when he was seized, during the afternoon, with a severe 
pain about the left clavicle and upper part of the left side of 
the chest. Great swelling had taken place since noon, so as to 
almost bury the clavicle. It .also extended up the neck. The 
integuments over the clavicle were red and oedematous. He had 
great difficulty of breathing, and the pressure on the trachea 
almost produced suffocation. I immediately made a dissection 
down to the clavicle, but no pus could be discovered. The bone 
itself was evidently enlarged, and my impression from the symp- 
toms was that pus was forming in its interior. The pain was 
less on the following day. 

On the 21st of April, the swelling about the clavicle had 
nearly disappeared, but the inner third of the bone was felt to 
be enlarged. From this period he slowly recovered, and left 
the Hospital free of complaint. 

Remarlcs. — The operation in this case was rapidly done, with 
no violence to the bladder, as shown by the symptoms at the 
time and afterwards, none of which had reference to that organ. 
The stone was small. Not being aware of the hardness of it, 
I thought it would yield to a small instrument. The power 
of this not proving sufficient, it was withdrawn, and another 
introduced; which, however, was so constructed as not to clear 
itself of the detritus or sand made by the crushing process. 
From this reason, the instrument which passed the obstruction 
caused by the stricture with ease, on its introduction, was ar- 
rested there on its withdrawal, from the jaws being imperfectly 
closed ; and some force was required, though not amounting to 
violence. 



212 GENITO-URINARY ORGANS. 

It will be perceived that the fragments of stone all came 
away within a week of the operation. In three days after its 
performance, pain in the shoulders began, after which all the 
symptoms denoting purulent absorption were manifested. The 
pulse, for six or seven days after the 17th, remained constantly 
very rapid, ranging from 190 to 212. There seemed to be a 
tendency to the formation of pus in different parts of the body : 
it was found about the metatarsal bone in the foot, and was pre- 
sumed to exist in the clavicle ; from the latter it was probably 
absorbed without making any appearance outwardly. 

This case will evidently come under the category of those 
placed by Velpeau and Civiale as instances of purulent absorp- 
tion, now called pyoemia, sometimes caused by the simple in- 
troduction of a catheter, but more frequently in lithotrity by the 
irritation of fragments lodged in the urethra, and about the neck 
of the bladder. 

The stone was analyzed by Dr. Bacon, who gave me the fol- 
lowing note of its constituents : " It consists chiefly of oxalate 
of lime : it also contains considerable uric acid, and a small 
quantity of carbonate of lime. The concentric layers are very 
numerous. In some fragments under the microscope, I counted 
from ten to twenty, or even more layers, in the space of one- 
fiftieth of an inch. The radiated structure is also seen under 
the same circumstances, the radii being still finer than the layers 
which cross them at rio^ht ano^les." 

Case CXVII. — Cystic Oxide Calculus. Lithotrity. 
Cure. — A man, aged 43, a resident of New York, applied to 
me in July, 1848. Seven years before, he was seized with a 
violent pain in his side, which was attributed to the passage of 
a calculus through the ureter. Shortly afterwards, a calculus 
of the size of a pea was voided with his urine. He had a num- 
ber of times since passed calculi. 

In April, while engaged in ploughing, he felt a pain in his 
bladder, the commencement of the sufferings from which he 
applied to be relieved. 

I sounded him with a small lithotrite, and detected a cal- 
culus, which measured an inch and a half. Slight irritation of 



STONE IN THE BLADDER. 213 

the bladder followed this examination ; and it was necessary to 
keep him quiet for a few days, and use remedies, before any 
operation could be performed. 

On July 13th, the bladder being injected with half a pint of 
warm water, the stone was immediately seized with the crushing- 
instrument, and broken, by means of the screw, without much 
difficulty. 

15th. He had suffered no inconvenience from the operation, 
and in fact felt relieved. A quantity of sand and fragments of 
stone had passed with the urine. 

The operation was repeated on the 18th, 23d, 26th, 29th, and 
Aug. 2d. After each operation he passed a number of frag- 
ments ; and once or twice it was necessary to remove, by the for- 
ceps, portions which had become lodged in the fossa navicularis. 
On Aug. 3d, a fragment which had been engaged in this way, 
and which it was found impossible to extract entire, was seized 
by a powerful pair of dressing forceps, crushed, and thus ex- 
tracted piecemeal. 

On the 9th he returned home well ; and on the 25th" I received 
from him a letter, in which he informed me that he had expe- 
rienced no difficulty in passing his water, and was otherwise in 
good health. 

Dr. Bacon kindly made an analysis of the stone, which is 
contained in the following note : — 

"The calculus, of which you sent me fragments yesterday for 
analysis, proves to be of a rare and interesting kind. It is com- 
posed of cystine or cystic oxide. The yellow portions consist 
of cystine in a state of purity, with the exception of a trace of 
phosphate of lime. In the white friable parts, which appear to 
be interspersed in the yellow masses without forming regular 
layers, the cystine is mixed with much phosphate of lime and a 
little triple phosphate. Your specimens agree pretty closely in 
physical characters with the description given by authors of 
this very uncommon form of calculus." 

This case of cystic oxide calculus is interesting from the ex- 
treme rarity of this kind of stone. M. Civiale, whose great 
experience is well known, states in his work on the stone and 
gravel, published in 1840, that he has met with but four cases 



214 GENITO-UKINARY ORGANS. 

of it. In the Hunterian Museum, out of six hundred and forty- 
nine calculi, it appears by the catalogue there are but three of 
the cystic oxide. 

It has been stated that an hereditary disposition existed in 
many of these cases ; two of those under the care of M. Civiale 
were brothers. In the present case this disease was not inher- 
ited, according to the account of the patient. 

Case CXVIII. — A veiy lay^ge Cystic Oxide Calculus. 
Sac in Bladder. Lithotrity. Deaths three weeks after- 
wards, from Inflamination of the Bladder, and Pyoemia. 
Diseased Kidney. — May, 1866. The following case is the 
first instance of death, after the operation for stone, which has 
occurred to me in a practice of over thirty years. The jjost- 
mortem appearances showed that this termination was almost 
inevitable. 

The patient was a shoemaker, of spare habit, and rather poor 
constitution ; and had been confined with a severe attack of 
pleurisy on the left side about a year before, soon after which 
his troubles commenced. The first symptoms were a pain in 
the urethra, and smarting on micturition ; the stream being 
suddenly checked, and restored again on a change of position. 
All these symptoms were aggravated, and had become insup- 
portable when I first saw him. 

I introduced gently a sound, and, detecting the stone, sent 
him to the Hospital. 

Being etherized, a small lithotrite was introduced. May 5, 
and the stone sought for. It was not at once seized, how- 
ever, though apparently of very large size. Finding some- 
thing uncommon in the case, I withdrew the instrument, which 
contained some flocculi of mucous membrane, and some calca- 

4 

reous fragments. The bladder was now injected with water 
more fully, a large instrument introduced, and the stone, meas- 
uring between two and three inches, seized. This was carried 
to the middle of the bladder, and crushed with some little force. 
The small fragments were then caught five or six times, and 
broken. The whole operation lasted less than five minutes. 
There was some fever on the following day, but the water 



STONE m THE BLADDER. 215 

was passed more freely than before. On the third day, there 
was tenderness over the bladder. During the next two weeks, 
many of the fragments were passed, though with difficulty. I 
had decided that he could not undergo the repeated operations 
for destroying so large a stone, and that, as soon as he was in 
a proper condition, I would remove the remaining portions by 
lithotomy. 

At the end of three weeks, when he had passed a day more 
comfortably than common, had taken solid food, and seemed to 
be improving, he was suddenly taken, in the night, with a faint- 
ness, and died. 

The following appearances were presented on examination. 
The bladder was greatly tliickened. On its posterior and upper 
part was a sac communicating with it, which was quite thin 
towards the peritoneum, and in a state of high inflammation. 
There was also peritonitis, but no rupture could be detected. The 
right kidney was about one-quarter its natural size ; its pelvis 
and infundibulum were greatly dilated, and filled with purulent 
matter and calcareous deposit ; the cortical substance, in a great 
measure, having disappeared. The ureter was thickened. The 
left kidney was about one-third larger than natural. Half of a 
cystic oxide calculus was found in the bladder, and weighed 
480 grains ; also a fragment weighing 22 grains. All the rest 
of the stone had been crushed, and had passed off by the urine. 
The whole stone must have weio^hed 960 OTains. The rio^ht 
lung was adherent at its apex. The left lung had very exten- 
sive pleuritic adhesions ; and, on cutting into its substance, pus 
escaped from various points, showing purulent absorption. 

It is probable, on the first exploration with the small litho- 
trite, that the stone was started from its bed in the sac, which 
inflamed, and gave rise to the subsequent symptoms. 

In addition to the preceding cases of cystic oxide calculus, I 
have had a third, in a man under my care for fracture of the 
thigh. Daring his confinement to bed, he was seized with 
violent symptoms referred to the kidneys, which subsided after 
the expulsion, ^:)er urethram^ of several minute calculi, which 
proved on examination to be composed of pure cystine. The 
urine also contained a deposit of cystine, in large microscopic 
crystals. 



216 GENITO-URINARY ORGANS. 

Case CXIX. — Oxalate of Lime Calculus. Lithotrity. 
Cure. — An Irish boy, 15 years of age, was brought to me 
in October, 1848, with symptoms of great irritability of the 
bladder, such as usually accompany the existence of a foreign 
body in that organ. At that time he declined all examination, 
although I warned him of the probable nature of the disease. 

In November, nearly a month afterwards, finding that no 
remedies had any effect in relieving his sufFeriilgs, he submitted 
to the operation of sounding, and quite a large calculus was 
discovered. 

His mother gave the following history of his case : He had 
been troubled in the urinary organs from infancy. When three 
years old, he had a violent attack of pain in the region of the 
right kidney, for which he was leeched and blistered. He re- 
covered for the time, but afterwards was seized with a pain lower 
down on the same side, attended with difficulty in passing water, 
and with bloody urine. From that time, he was almost con- 
stantly troubled. He was obliged to pass his water every half 
hour, and it escaped involuntarily during sleep. He could not 
walk fast without pain, and passed blood occasionally. 

On account of the size and hardness of the stone, and the age 
of the patient, I advised the operation of lithotomy; but the 
parents would not listen to a cutting operation, where any other 
method was available. I therefore determined to etherize the 
patient, make an attempt with the crushing instruments, and, if 
the stone was found to resist farther than was thought safe, to 
relinquish this operation and advise lithotomy, which his friends 
would probably consent to when the former was found to be im- 
practicable. 

On Nov. 16th, the first operation was done ; the bladder was 
injected ; the crushing instrument passed in, and the stone seized. 
It measured one and a half inches. Attempts were made to 
crush it by means of the screw ; but this was found impossible 
on account of its hardness. The hold was therefore relaxed, 
the stone seized in a new position, more on one side, and was 
then broken down without any great violence. The fragments 
were crushed a second and a third time. 

He suffered somewhat in the bladder after the operation. A 



STONE IN THE BLADDER. 217 

number of fragments of the calculus were passed, which, on 
being analyzed, were found to consist of the oxalate of lime, 
combined with the triple phosphate, which showed itself in 
glittering transparent crystals. The latter seemed to have been 
deposited on the surface, and were exceedingly sharp and irri- 
tating to the touch. 

20th. The operation was repeated ; the stone, when first 
seized, seeming to resist the action both of the screw and 
hammer : but, after a little perseverance, it was finally crushed 
by percussion. 

The following morning, a number of pieces were passed, and, 
among others, apparently the original calculus from the kidney : 
it was of a lightish-brown color, about the size of a small bean. 

The operation was repeated six times at intervals of a week. 
The time devoted to the seizing of the stone was generally about 
five minutes. From the great hardness of its composition, it 
could not be crushed into sand, as is the case with the phosphatic 
and uric-acid calculi. The fragments were large, and required 
to be seized and crushed separately. 

Twice in the course of this period, portions became engaged 
in the orifice of the urethra ; and it was necessary to administer 
ether, and extract them, as the canal was so sensitive that noth- 
ing could be done without the assistance of this agent. Finally, 
the last fragment of the stone, which for some days had been 
lodged in the neck of the bladder, and which I had once pushed 
back, became suddenly fixed at the membranous part of the 
urethra, so as to entirely obstruct the course of the urine. To 
disengage this, Hunter's forceps were introduced : the stone was 
at length caught, and drawn to the fossa navicularis. From 
this spot it was found impossible to extract it without laceration 
of the urethra : the hold on it was therefore relinquished, and, 
by the use of forceps, portions were gradually broken away un- 
til the whole was removed. 

The patient, after this, fully recovered ; no symptoms remain- 
ing to denote the existence of an irritation of thirteen years' 
standing. 

28 



218 GENITO-UEINARY ORGANS. 

Case CXX. — Vesical Calculus. Lithotrity. Recovery. 
— A gentleman, 30 years of age, consulted me in November, 
1853. He had the first symptoms of the disease in 1843. He 
had previously, after a nephritic attack, passed a small calculus 
from the urethra. The symptoms, at the time of the operation, 
were great pain, a frequent desire to pass water, bloody urine, 
and inability to bear the jolting of any vehicle. The water was 
passed every half-hour, both day and night. The measure of 
the calculus, when first seized by the lithotrite, was fourteen 
lines in diameter. It was easily crushed, with scarcely any 
pain ; fragments passed off, without difficulty, in the course of 
twentj^-four hours. The operation was repeated three times in 
a fortnight, without the use of ether, giving scarcely any more 
uneasiness than an ordinary case of catheterism ; and the patient 
was perfectly relieved in about three weeks. 

Case CXXI. — Vesical Calculus. A Pebble for Nucleus. 
Bilateral Lithotomy. Recovery. — On Nov. 7, 1847, I saw 
in consultation a child four years of age, affected with symptoms 
of some foreign substance in the bladder. The child was thin, 
delicate, and tall for his age. The history of his disease was as 
follows : — 

Two years and a half previously, as the child was making 
water in the street, a boy, in attempting to wrest a knife from 
him, pulled him over, and dragged him through a heap of 
gravel. When taken up by his mother, a quantity of this sub- 
stance was found adherent to the glans penis. For twenty-four 
hours, he had an almost complete stoppage of water. At the 
end of that time, an examination being made, disclosed a small 
bit of gravel lodged just within the orifice of the urethra. It 
was removed by a knitting-needle, and immediate relief obtained. 

Some months after the preceding occurrence, the child began 
to complain of difficulty in passing his water, attended with fre- 
quent desire to evacuate the bladder. These symptoms, with 
intervals of ease, continued till within a few months of the time 
when I saw him. Then they became much aggravated, so as 
to make it imperative to have active measures taken for his re- 
lief; the sufferings both by day and night being almost constant, 



STONE IN THE BLADDER. 219 

and the calls for evacuating the bladder incessant. All attempts 
at an introduction of a sound being resisted, he was etherized, 
and I discovered a calculus. 

On Nov. 16, an operation having been determined on, the 
child was fully etherized, and a sound placed in the bladder. 
Lithotomy was performed by the bilateral method ; the incision 
of the prostate being made with a straight, probe-pointed bis- 
toury. The stone was removed by a large polypus forceps. 
No bad symptoms followed the operation. 

On the following day, the water passed by the urethra ; on 
the third, by the wound ; and continued to do so for a week, 
when it resumed its natural course. 

On page 95 of the "Appendix to Etherization, with Surgical 
Remarks," will be found a description of the stone, with some 
comments upon its presumed method of introduction, by Dr. 
J. C. Warren, in these words : — 

" The stone was about half an inch long, the fourth of an 
inch thick, and in form of a flattened oval. It was sawn by 
Dr. J. B. S. Jackson. The exterior layer consisted of a whit- 
ish deposit, the sixteenth of an inch in thickness, and composed 
apparently of triple phosphate. The layers within this were of 
a brownish color, like that of the phosphate of lime, and were 
about half a line in thickness. In the midst of these was a 
harder substance, about a line in diameter, which appeared to 
be silicious. Its outline could not exactly be distinguished from 
the surrounding layers of brown deposit. 

" The retrograde passage of the apparent nucleus into the 
bladder may excite surprise, unless we take into consideration 
the inverted action of the urethra, by which bodies received into 
it are so often conveyed from without into this organ, where 
they serve as the nuclei of stones. The introduction of this 
nucleus may receive an additional explanation from the fact, that 
the gravel-stone, removed by the mother, prevented the passage 
of urine forced into the urethra by the strong contractions of the 
bladder ; and this, not escaping, was driven back by the contrac- 
tions of the urethra, carrying along the inner stone, which 
formed the nucleus." 

The first of the following cases illustrates the ordinary bi- 



220 GENITO-UKINARY ORGANS. 

lateral operation of Dupuytren, and may serve to compare this 
method with that adopted in the next case, where the primary 
incisions were novel, but the final ones identical with those of 
Dupuytren : — 

Case CXXII. — Vesical Calculus. Bilateral Lithotomy. 
Recovery. — A boy, 12 years old, had been troubled for two 
or three years with a want of power to retain his urine : the 
suffering had been excessive, both by day and night. He was 
in a very miserable and emaciated condition, but had recently, 
however, for a few weeks, been much more comfortable ; a 
fact which was afterwards explained by finding the stone fixed 
in the upper part of the bladder. The prepuce was very long, 
owing to the habit of constantly pulling at it. On sounding 
him, under ether, the stone was felt in the upper part of the 
bladder. It was decided to perform lithotomy, which was done 
by the bilateral method of Dupuytren. A sound of good size 
was introduced, making a great curve outward, so as to project 
well in the peringeum. A semilunar incision was then made 
above the anus, and the staff reached at the membranous por- 
tion of the urethra. Dupuytren's double lithotome was now 
passed into the bladder, with its concavity upwards ; and, the 
sound being removed, the instrument was reversed, its blades 
opened to the extent of seven-eighths of an inch, and with- 
drawn. The forceps were now introduced ; the finger having 
previously been used to explore the stone, which was found 
firmly adherent to the upper part of the bladder. The stone 
was seized with some difficulty, owing to the firm adhesions 
which it had contracted with the folds of the mucous membrane ; 
but it was finally extracted without injury to the organ. It 
proved to be a mulberry calculus, very rough and irregular in 
outline, and weighing 180 grains. A piece of elastic catheter 
was kept in the wound for twenty-four hours, after which it was 
dispensed with. On the third day, a little water was passed by 
the urethra ; and, on the tenth day, it had entirely resumed its 
natural channel. All the distressing symptoms of stone were 
immediately relieved by the operation ; and, at the end of three 
weeks, the patient was discharged well. 



STONE IN THE BLADDER. 221 

Case CXXIII. — Vesical Calculus. Median Lithotoimj. 
Recovery. — A boy, 13 years old, entered the Hospital in 
March, 1863, on account of great suffering in the region of the 
bladder, accompanied by incontinence of urine. Two years 
before, he noticed an occasional difficulty in passing water ; at 
times a sudden stoppage of the stream occurred, and the urine 
was now and then a little bloody. The symptoms became more 
urgent, and the pain constant, so as to confine him to his bed. 
The urine dribbled away, and irritated the skin of the penis, 
scrotum, and thighs. The prepuce, as in the last case, was 
much elongated. 

On introducing a sound, the instrument encountered much 
resistance at the neck of the bladder, but finally passed in and 
came in contact with a stone. The bladder was quite empty 
of urine ; and the calculus meeting the sound at different 
points, while enveloped in the mucous folds, gave the impres- 
sion of the existence of two or more stones. 

It w^as decided to perform lithotomy, after relieving the 
external irritation by cleanliness and suitable dressings. 

The operation which was performed combined some of the 
more important features both of the median and bilateral 
methods, and seems to offer some advantages over either. A 
sound of medium size was passed into the bladder ; the meatus 
urinarius, which had become very much contracted, being first 
slightly enlarged by the knife. The skin was then divided in 
the median raphe, and the dissection continued in the same line 
until the membranous part of the urethra was exposed. This 
was next opened, and the attempt made to introduce the double 
lithotome cache of Dupuytren. Owing to the unyielding 
condition of the neck of the bladder, the lithotome could not 
readily be passed in ; a probe-pointed bistoury was therefore 
substituted for it, and the prostate divided on both sides. The 
finger now entered with ease, and a large stone was felt very 
high up in the bladder. Attempts were made to extract it 
with a long pair of polypus forceps, and then with the ordi- 
nary lithotomy forceps, but without success, owing to its great 
size ; the cut in the prostate was therefore enlarged, and 
the attempts at extraction renewed,, but stiU unsuccessfully. 



222 GENITO-URINARY ORGANS. 

As it was not deemed safe to enlarge the incision in the prostate 
further with the knife, the two forefingers were introduced, back 
to back, and the substance of the gland slightly torn. A larger 
pair of forceps was then passed in ; and, by embracing the whole 
stone within its jaws, it was extracted without further difficulty. 
A piece of catheter was placed in the wound, and the patient 
sent back to bed. 

On the ninth day, the urine began to pass through the urethra ; 
and, from the twelfth day, none escaped by the wound. At the 
end of three weeks, the patient was discharged, with the external 
wound nearly healed, and free from all symptoms of stone. 

The calculus, which appeared to be composed of the triple 
phosphate of magnesia and ammonia, was large and very rough : 
it measured 3^ inches in its longest circumference, and 2^ in 
the shortest; its weight was 240 grains. 

I was led to perform the operation in the manner related ; 
viz., by making an incision through the skin in the median 
raphe, instead of the cross cut employed by Dupuytren, as 
illustrated in the first case, from having observed how easily 
these parts could be dilated in the incisions practised in perineal 
section for the division of strictures, frequently impassable by 
the smallest sound. In these cases, after cutting through a 
deep perinaeum filled with inflammatory exudation, it is often 
found necessary to exercise much patience, and to spend much 
time in tracing the urethra beyond the stricture. Having had 
occasion, during the past few years, to do a number of these 
operations, most of them entirely without any guide, I was led 
to the reflection, that it would be very easy in this way to per- 
form the operation of lithotomy when the operator is guided by 
the presence of a large stafl" in the urethra. When the median 
section is performed deliberately, the operator has the parts 
divided freely open to the view ; which is not the case in 
Dupuytren's operation, which has to be performed mainly by 
the sense of touch. By this method, also, the vessels are 
much less likely to be wounded than in the common operation. 
Although different kinds of operations must of necessity be 
practised to suit different cases, the present method would seem 
to be the most direct an^l natural one for arriving at the blad- 



STONE IN THE BLADDER. 223 

der. Since performing it, I have found that a similar opera- 
tion had been suggested by Mr. Erichsen, who had not at that 
time, however, performed it upon the living subject. Mr. 
Allarton's and Mr. Beaumont's operations, although done in 
the median line, are essentially different. 

I have in my possession a large calculus, removed from the 
body of a gentleman after death, which had been lodged behind 
the prostate. He had suffered with it for many years ; and, 
finally, it was the cause of his death. He had been sounded 
by a number of distinguished surgeons, and by some declared 
to have a stone, by others not. From this reason, he had 
deferred, for many years, submitting to an operation. By 
sounding under ether, and turning the beak of the instrument 
backwards, I detected a stone ; but an operation was thought 
inexpedient, on account of the great disease existing in all 
the urinary organs. After death, the kidneys were found 
extensively ulcerated, the ureters enlarged, and the bladder 
greatly thickened and sacculated, with a cavity or depression 
behind the enlarged prostate, in which the calculus was lodged 
and partially concealed. 

Case CXXIY. — Vesical Calculus of Oxalate of Lime in 
a Child three years old. Bilateral Operation. Recovery. — 
March, 1857. The symptoms appeared a year and a half 
before. The sufferings were intense, preventing sleep, and 
producing all the usual symptoms of stone in the most aggra- 
vated form. The patient had been twice sounded, while under 
the influence of ether, by experienced surgeons ; but no stone 
was detected. After etherizing him, I introduced a common 
sound, l3ut, with the most careful examination, assisted by the 
finger introduced into the rectum, failed to find any calculus. 
The instrument was therefore withdrawn, and a sound with a 
slight curve at its end, somewhat similar to the one described 
by Mercier for exploring the prostate gland, was used. This, 
being passed in, and taking up less room than the common 
sound, at once struck a stone, which lay very high up in the 
bladder. 



224 GENITO-URINARY ORGANS. 

I at first proposed to destroy the stone in this case by the 
crushing process, but soon found that the bladder was too much 
contracted to contain sufficient water to allow the instrument to 
be manoeuvred safely. The bilateral operation was performed, 
and a large stone removed. The coats of the bladder were 
much thickened, and its cavity greatly elongated, so that quite 
a long pair of forceps was required to reach and dislodge the 
stone. The patient slept soundly the night after the operation, 
being the first good night's sleep he had enjoyed for more than 
a year. At the end of a week, the urine passed by the ure- 
thra ; and, in another week, the child went home well. 

Case CXXY. — Vesical Calculus of eighteen months' stand- 
ing. Median Lithotomy. Recovery. — A boy, 4|^ years 
old, had always enjoyed good health, with the exception of the 
following symptoms, which had lasted about eighteen months. 
At first, he was obliged to pass his water more frequently 
than usual, — as often as twelve times during the twenty-four 
hours. He soon had great difficulty in inducing the flow of 
urine, making bearing-down efforts, and exhibiting signs of 
pain. A correct diagnosis was not made. Owing to constant 
pulling, to relieve the pain at the end of his penis, the prepuce 
was greatly enlarged. His health was much reduced ; his sleep 
was interrupted by pain, and desire to pass urine, which dribbled 
away. 

On entering the Hospital, he was etherized and sounded, when 
a calculus, about the size of a filbert, could be easily felt. The 
urethra was found unusually capacious. 

Four days afterwards, the patient was again etherized ; the 
bladder was filled with warm water ; an ordinary grooved staff 
introduced ; and an incision, about one and a quarter inches 
in length, made in the median line of the perinseum.- The 
staff being reached, a probe-pointed knife was passed along the 
groove, and a lateral incision was made through the prostate. 
This incision was made bilateral by the lithotome cache. The 
calculus was extracted with some difficulty. The dust from 
the calculus consisted of oxalate of lime, carbonate of lime, triple 
phosphate of ammonia and magnesia, and urate of ammonia. 



STONE IN THE BLADDER. 225 

On the third day after the operation, he passed a little water 
by the urethra ; it then stopped, and for four days passed by the 
wound ; after which, it passed entirely by the urethra. 

About a fortnight after the operation, the patient exhibiting 
some symptoms indicating the presence of calculus, a sound 
was introduced into the bladder ; but nothing was discovered. 

A month later, the child was seen again, after a visit of ten 
days in the country. He was in a state of perfect health, his 
whole condition having been entirely changed by the removal of 
the stone. 

Case CXXYI. — Vesical Calculus. Median Lithotomy.- 
Recovery. — June 17, 1865. A boy, aged 31 years. The 
symptoms were first noticed when the child was but little more 
than a year old, and were as follows : water passed often, 
attended with difiiculty and pain, at times dribbling away in 
drops ; sleep much disturbed ; phimosis. 

For over a year, he continued to grow worse. In the autumn 
of 1864, according to medical advice, took cod-liver oil, which 
improved his general health. During the winter, micturition 
was involuntary. His appetite was good, and he slept well 
when not disturbed by pain. 

On entering the Hospital, an examination was made while 
the patient was under the influence of ether. The prepuce was 
found to be almost impervious, admitting only a small probe 
through its aperture. It was slit up along the dorsum of the 
glans, and the raw edges were brought together by a few sut- 
ures. A sound was passed into the bladder, when the calculus 
was easily detected. Analysis of urine showed it to be cloudy, 
light-colored, with considerable precipitate of a ropy character. 
It was albuminous, corresponding to the deposit of pus corpus- 
cles ; very faintly alkaline. Under the microscope, a large 
number of crystals of the triple phosphates, interspersed with 
pus and mucus corpuscles were observed. 

A few days afterwards, the median operation was performed, 
as detailed in the previous case, and a very large calculus re- 
moved with much difficulty, notwithstanding the prostate was 
notched on both sides after the first section. The effect of the 

29 



226 GENITO-URIlSrARY OEGANS. 

operation was at once to entirely relieve the patient from pain. 
The third day after, he passed a few drops of urine by the 
urethra ; at the end of a week, the water passed freely by the 
natural passage ; at the end of two weeks, he went home quite 
well. 



STRICTURE OF THE URETHRA, WITH RETENTION OF 
URINE. 

I do not propose to enter into the treatment generally pur- 
sued for strictures of the urethra, but think it of great impor- 
tance to allude to those cases where, from some accidental 
cause, a sudden retention takes place, attended with alarming 
symptoms. The surgeon's first impulse is to relieve the patient 
by the use of an instrument. This is frequently found impos- 
sible, and it is abandoned, leaving the patient in a worse condi- 
tion than before : in fact, a passage already excessively small 
has become almost obliterated by swelling, and, of course, no 
instrument can be made to penetrate it. Nothing, indeed, 
needs greater forbearance on the part of the surgeon than to 
restrain himself from instrumental interference, when the patient 
is crying out in agony to be relieved from his suffering. The 
course which I have generally found successful in such cases is 
as follows : First, where it is possible to temporize, to give an 
opiate enema. Second, to cover the perinaeum and lower part 
of the abdomen with anodyne fomentations. By these means, 
sleep is generally produced, attended with profuse perspiration ; 
and, when the patient awakes, he can empty the bladder. 
Sometimes, even during sleep, the urine gradually trickles 
away. After this, by pursuing an antiphlogistic course for a 
day or two, a small bougie may be passed, and the stricture 
treated in the ordinary way by dilatation. Third, if the suifer- 
ing is excessive, and the distention so great as ordinarily to 
indicate puncture of the bladder by the rectum, the patient may 
be etherized, when, by passing down a filiform bougie, and 
inserting it partially into the stricture by a twirling motion, I 
have often seen the urine at once begin to flow by its side ; and 
in one or two instances, on withdrawing it, a small stream 



STRICTUEE OF THE URETHRA. 227 

followed, which continued to flow until the bladder was com- 
pletely emptied. 

In a patient who applied to me, not long since, for the treat- 
ment of a stricture of long standing, I found that it was impos- 
sible to pass a filiform bougie. He was, therefore, put under 
treatment, and instruments abstained from. A few days after- 
wards, he was seized with a chill, and sent for me to visit him. 
Not being able to attend, I requested a friend to see him. He 
found a large, hard tumor over the pubes, and a retention of 
urine. The patient, however, complained of no pain, although 
the case seemed almost to indicate the necessity for some surgi- 
cal interference. The condition of things being reported to me, 
I advised the treatment by opiates and fomentations, as above 
suggested. It was followed, in the course of the night, by 
relief to the bladder. On the succeeding day, the tumor still 
existed, though not quite so large as on the preceding day ; and 
the patient stated that he had noticed it for the previous eight 
months, though smaller than in this attack. I saw him some 
weeks subsequently, with the tumor undiminished in size, al- 
though a good-sized bougie could be passed through the strict- 
ure, where, at first, none would penetrate. The tumor was 
doubtless the bladder in a thickened condition, partially filled 
with water, and was the result of long-continued obstruction to 
its delivery. 

Case CXXYH. — Retention of Urine relieved by Intro- 
duction of Capillary Bougie and Ojoiate JEnema. — A 
young man, 28 years of age, on retiring at night, found that 
he was unable to urinate, and, in the morning following, also 
failed to do so. Five years before, he had gonorrhcea : this 
was followed, two years subsequently, with complete stoppage 
of urine, which was relieved by the use of a catheter, and since 
he had never made a full stream. He consulted a physician, 
who tried to introduce an instrument, but was unable to accom- 
plish it. He was then directed to me in a very suffering state, 
with the bladder much distended. I at once introduced a capil- 
lary bougie of the smallest size, which passed into, but not 
through, the stricture. On withdrawing it, the m'ine began to 
dribble away. 



228 GENITO-URINAEY ORGANS. 

He was then directed to go to the Hospital, where he had a 
warm bath given him, and an enema of forty drops of tincture 
of opium in a wineglass of starch. In about four hours after 
this, he was able to empty his bladder, making quite a fair 
stream. He remained in the Hospital a number of days, until 
he could be safely discharged, declining any systematic treat- 
ment for his stricture. 

Case CXXVHI. — Stricture of Urethra. Hetention of 
Urine, Relieved hy Capillary Bougie. — A man, 35 years of 
age, was brought to me on a Sunday morning in November, 
1861, suffering greatly from inability to pass his water. Some 
years before he had gonorrhoea, the effect of which lasted for the 
better part of a year. He indulged freely in ardent spirits. 
On Saturday, after getting wet in a storm, he was taken with 
a stoppage of water. Every means were tried by his physician 
to relieve him. On Sunday, finding all applications fail, he 
sent him to me for advice. I found the bladder distended. 
My first disposition was to send him to the Hospital, and try 
the efifect of antiphlogistic and narcotic remedies, before at- 
tempting the use of any instrument, as the catheter had been 
already tried without effect, only producing a discharge of 
blood. His pain, however, was so excessive, that I decided to 
attempt the use of a means which, three times before, I had 
found effectual in cases of retention attended with very close 
stricture. Taking one of Charriere's smallest bougies, almost 
capillary, I gradually passed it down the passage, and carefully, 
without pressure, worked it into the stricture, which took a firm 
hold upon it. The patient being cautioned not to strain, it 
was now slowly withdrawn, when a small and irregular stream 
of water followed. He was requested to stand up ; and slowly, 
by jets, some blood now and then passing out, the bladder 
was freed, and almost entire relief from the excessive tor- 
ment obtained. The patient was sent to the Hospital, a 
warm bath given, and an enema of forty drops of tincture 
of opium after it. 

He had a good night ; and on the following morning passed 
his water easily. He was kept on a liquid diet, and on the 
13th left quite well. 



STKICTURE OF THE URETHRA. 229 

Case CXXIX. — Gutta-percha Bougie brolcen off in the 
Urethra. Fragments ejected spontaneously. — 1853. A 
young man applied to me while suiFering under an obstruction in 
passing water, for which he had been subjected to much treat- 
ment, without relief. He had contracted a gonorrhoea nine 
months before, and had a gleet since. The symptoms indicating- 
stricture, he was advised to have the urethra explored. A 
small wax bougie was first selected from a bundle, but rejected 
from being a little injured. The next that offered was one of 
gutta percha ; and, being of the requisite size, it was softened in 
the hand, and passed up readily to the prostatic portion of the 
urethra. Meeting here with some obstruction, it was with- 
drawn, the point a little softened and bent, and it then went 
easily into the bladder, without the use of any force. On tak- 
ing hold of the instrument to withdraw it, after it had remained 
a minute or two in sitic, it broke off short at the orifice of the 
urethra ; or, rather, dropped off, as not the least violence was 
applied to it. I requested the patient to stand perfectly still, 
not having any question at the time but that, with a forceps, it 
could be seized, and readily withdrawn. This was found im- 
practicable. It seemed to retract, and bury itself in the anterior 
wall of the urethra ; and any attempt at seizing it only resulted 
in laceration of the lining membrane. Various instruments 
were tried, which I had generally employed in withdrawing 
foreign substances ; but, from the peculiarly soft nature of the 
material in the present instance, and its small size, it could not 
be detected or seized. EflTorts were made, by passing the finger 
into the rectum and by manipulations on the external part of the 
urethra, to force the fragment forwards ; but, from the reasons 
mentioned above, viz., its softness, small size, and its not dis- 
tending the canal so as to make itself perceptible, nothing could 
be effected in this way. The patient was sent to the Hospital ; 
and as it was found practicable to pass a catheter by the side of 
the bougie, and free the bladder, it was concluded not to cut 
down for the purpose of removing it, but for the present to leave 
the case, so long as the symptoms were not urgent, and see 
what nature would effect. He was ordered a warm bath, and 
confined to his bed on a liquid diet. The day following, he was 



230 GENITO-UKINAEY OKGANS. 

free from pain, and had passed water while in the bath. On 
the third day, he observed a hard substance through the walls of 
the urethra, making its way towards the orifice": this he assisted 
a little, and extracted a bit of bougie an inch in length, very 
brittle, and shrivelled up. On the fifth day a still larger piece 
was passed, and on the sixth the remainder of the instrument, 
making in all about seven inches. He suffered very little from 
its presence in the urethra, his principal complaint being the 
soreness of the urethra near the meatus, caused by the attempts 
made to extract it ; which, however, had been conducted with 
the utmost care, and soon discontinued, as they were found to 
be useless. The patient quickly recovered, and was completely 
relieved from his previous troublesome disease. 

I have often used the gutta-percha bougies for taking impres- 
sions of strictures, and, until the present case, had never expe- 
rienced any accident from them. In order to be employed with 
safety, they should be made fresh when required for use, as 
they become extremely brittle on exposure for any length of 
time to the air. 



PERINEAL SECTION. 

Mr. Syme, of Edinburgh, was the first to call the attention 
of the profession to this operation for the relief of stricture. 

In the "American Journal of Medical Sciences for 1861," I 
published a paper upon this subject, in which I advocated the 
extension of the operation to a class of cases not included by 
Mr. Syme; viz., to those strictures in which instruments are 
impracticable, arising either from injury or disease. Mr. Bryant 
recommended for them, in Guy's Hospital Reports, puncture of 
the bladder through the rectum. In a number of instances, I 
have introduced a staff" as far as the stricture ; and then, cutting 
down upon it, searched for the continuation of the urethra, 
and, when found, divided it by careful touches of the knife. 
If the urethra is found with difficulty, the patient may be 
allowed to recover from the influence of the ether sufficiently 
to make an effort to pass water, and then the bulging portion 
of the urethra near the bladder can be pierced, and the stricture 



PERINEAL SECTION. 231 

divided from behind forward till the end of the staff is reached ; 
or, without this assistance, the urethra may be immediately cut 
down upon near the bladder. 

A few cases are selected, which show the advantages of peri- 
neal section, even in the most desperate cases. 

Case CXXX. — Organic Stricture of the Urethra of ten 
years' standing. The Urine finally passed in Drops. Re- 
tention. Perineal Section. Division of the Stricture. Com- 
plete jRecovery. — A man, about 30 years of age, entered the 
Hospital on April 30, 1860, with a stricture of the urethra 
of ten years' duration. The w^ater, when he entered, passed 
in a very small stream ; and it Avas constantly dribbling during 
the night, accompanied with a purulent discharge. He com- 
plained of pain in the renal region, though not of a severe 
character. After very careful attempts to pass a bougie of the 
smallest description, it was finally decided to incise the stric- 
ture from within, which was done on May 15th with temporary 
relief. 

On May 26th, the urine became less free ; there was consider- 
able dulness in the pubic region ; and the patient complained of 
pain about the bladder, with general uneasiness. 

On the next day, I found he had a complete retention of 
urine, and proceeded at once to perform perineal section. He 
was placed on a table on his back ; and after being thoroughly 
etherized, so that his joints w^ere fully relaxed, he was tied, as 
in the operation for lithotomy. I have found it much better to 
confine the limbs in this way, than to intrust them to the care of 
assistants, who are apt to be worn out during an operation so 
likely to be long and tedious. A small staff was introduced ; 
and it seemed to penetrate the first stricture, which was incised 
about a couple of weeks before, and brought up against a second, 
apparently just behind the root of the scrotum. The fore- 
finger of the left hand was then introduced into the rectum, 
and the situation of the prostate ascertained. The perineum 
was then divided, and a careful dissection made to ascertain the 
site of the urethra. This was rendered very tedious by the hem- 
orrhage from the bulb at the bottom of the deep wound, which 



232 GENITO-URINARY ORGANS. 

in this case was more than ordinarily troublesome. The urethra, 
however, was finally opened directly in front of the prostate, 
and a large gum-elastic catheter passed through the wound into 
the bladder, giving exit to a very large quantity of urine. The 
canal was now opened forwards, and the callosities freely divided, 
until the staff was reached. A second gum-elastic catheter was 
now passed downwards, through the penis, until it appeared in 
the wound : the ivory end of the first having been cut ofi", the 
point of the second was insinuated into it, and firmly fixed. In 
this manner it was dragged up through the whole extent of the 
urethra. In similar cases, where it is difficult to find the ure- 
thra, and where other means have failed, the course might be 
pursued which was adopted in the present case. I allowed the 
patient partially to recover from the ether ; stimulated him to 
make an effort to urinate ; and when the urethra, behind the 
stricture, became dilated, a minute stream of urine issued, indi- 
cating the spot for the introduction of a probe, and the urethra 
was found. 

No unpleasant symptoms followed the operation : the patient 
was comfortable, and relieved from the sense of fulness caused 
by the distended bladder and ureters. At the end of a week, 
the first catheter, being removed, was found to have been par- 
tially acted upon by the urine, and its calibre somewhat 
obstructed ; it was replaced by another. 

At the end of a month, he was able to introduce the instru- 
ment himself; and, at the end of two months, the wound in the 
peringeum having healed, he kept it in at night, leaving it out 
during the day. 

He shortly after left the Hospital entirely well. 

Case CXXXI. — Stricture of the Urethra of twenty-five 
years' duration. Numerous Urinary Fistulce in the Scrotum 
and Perinoeum. Perineal Section. Cure. — A man entered 
the Massachusetts General Hospital on April 24, 1860, and 
gave the following history of himself. He had suffered from 
gonorrhea twenty-five years previously : he then had a slight 
stricture, which, after fifteen or sixteen years, became so tight 
as to give him a great deal of inconvenience, for which he 



PERINEAL SECTION. 233 

entered the Hospital under my care, and was treated by internal 
incision. This relieved him for a time. In 1858, a fistulous 
opening appeared in the perinaium, followed by two in the 
scrotum : through these openings, purulent matter, with urine, 
was freely discharged. The whole of the scrotum was tense, 
indurated, and burrowed by sinuses. Two months previous to 
his admission, a No. 1 bougie was passed into the bladder after 
much effort, by which his symptoms were aggravated. 

I passed a No. 1 bougie down to the stricture, and kept it 
applied for two or three hours daily, exerting a gentle pressure 
against the stricture. After treatment for about a week in this 
way, the stricture gave way, and the instrument passed into the 
bladder. 

Notwithstanding the passage of the bougie, the disease of the 
scrotum increased ; and towards the 1st of June, the stricture 
having again closed, so that it was quite impossible to pass any 
instrument, perineal section was done at his request, on June 
4th. 

He was etherized, and confined in the position for lithotomy. 
Syme's sound was passed through one stricture, and encountered 
a second. An incision was made in the median line of the peri- 
n^eum, until the point of the staff was reached. The dissection 
was tedious, from the hardening of the tissues by infiltration, 
and on account of the hemorrhage, which was very free : the 
perinteum also was uncommonly deep. In order to see more 
clearly the continuation of the urethra beyond the stricture, the 
end of the staff was turned out through the incision, and served to 
hook up, and thus bring the deeper parts more fully into view. 
The wound being freely sponged with iced water, a puncture was 
made into the urethra, in the neighborhood of the neck of the 
bladder, into which a probe was passed, and the urine allowed 
to escape. A large gum-elastic catheter was substituted for the 
probe. A sharp-pointed knife was passed up by the side of a 
small Syme's sound ; and the first stricture, which lay behind 
the middle of the scrotum, was freely divided. The catheter 
was drawn up through the urethra, as in the last case. 

The first catheter was left in place a week ; then, becoming 
obstructed, it was replaced by another, and this was done weekly 

30 



234 GENITO-URmARY ORGANS. 

through the course of the treatment. The wound in the peri- 
naeum, on account of the diseased state of the tissues, was very- 
slow in healing ; and the patient remained in the Hospital for 
two months afterwards. 

A communication was received from him in November, 1860, 
in which he stated that he was entirely well. 

Case CXXXII. — Tramnatic Stricture of the Urethra 
of jive years' duration. Vesico-rectal Fistula. — A teamster, 
36 years of age, came into the Hospital under my care in the 
early part of the spring of 1860. He said that, five years 
before, he had been jammed against a wall by the buffer of 
a freight-car, with such force as to produce a rupture of the 
urethra. He remained in a critical situation for a time, and had 
never since been able to pass his water except in a very small 
stream. 

On examination by the rectum, I found that the bladder, 
intestine, and surrounding parts, were glued together, and 
involved in an indurated mass, and the calibre of the intestine 
was very much diminished. Fistulae had formed by the side of 
the rectum, and there was communication between the bladder 
and the rectum. A probe being introduced into the fistula by 
the side of the rectum, passed up by the side of the intestine, 
through the indurated tissues, and apparently entered the inte- 
rior of the bladder. No ordinary means afforded relief; and I 
advised him, unless willing to have perineal section performed, 
to desist from any further efforts, for fear of producing irritation 
and complete retention, especially as he did not suffer much 
from his disease. 

In June, having heard of the success of perineal section in 
other cases, he came back to the Hospital for the purpose of 
having it performed upon himself. 

The operation was performed, and a catheter introduced, as 
in the first case. 

Not the slightest unfavorable symptom followed ; but at the 
end of the week, when it was necessary to replace the catheter, 
the end of the instrument escaped into the rectum. This was 
prevented by hooking the beak of the instrument against the 



PERINEAL SECTION. 235 

pubes ; and then, instead of trying to force it forwards, the han- 
dle was suddenly depressed, and it slipped into the bladder. 
Carried forwards in the ordinary way, it always went into the 
rectum. 

Before the end of the month, the urine was passed by the 
catheter, although there was purulent discharge through the fis- 
tulous opening near the rectum, and occasionally from the 
rectum itself. The patient remained in the Hospital rather more 
than two months, when he left, and has since been seen well. 

Case CXXXIII. — Urethral Fistula from Bullet -wound. 
Perineal Section. Recovery. — A young man, 20 years of 
age, entered the Hospital, June 3, 1865, having been wounded 
in the attack on Fort Steadman in the preceding March. The 
ball grazed the side of the penis, taking out a piece of the pre- 
puce, and, passing through the scrotum, carried away the right 
testicle. It then penetrated the deep muscles of the perinseum, 
following the course of the urethra, and came out just below 
the margin of the anus. When wounded, he was in an erect 
posture ; he fell insensible, and was at once carried to the rear. 

On entering the Hospital, the entire wound was found to 
have healed, with the exception of the fistulous opening below 
the anus. He was obliged to urinate once in two or three 
hours, and the greater portion of the water escaped through the 
wound near the anus. He had previously been repeatedly 
informed that nothing could be done to relieve him. On ex- 
amination, a stricture was found near the prostatic portion of the 
urethra; and a bougie, introduced into the meatus, emerged at 
the anal opening of the wound. I directed that a bougie should 
be inserted daily down to the stricture. On June 28th, the usual 
operation for perineal section was performed. The end of the 
sound being reached, the posterior portion of the urethra was 
found involved in a mass of cicatricial tissue ; and great diffi- 
culty was experienced, after the wound was enlarged, in finding 
the orifice of the urethra which led to the bladder. 

This, beino' found, was freelv divided, and a lars^e ofum-elastic 
catheter introduced through the whole course of the urethra. 
On the following day, he was quite comfortable. On the 8th 



236 GENITO-URINAKY ORGANS. 

of July, the catheter was removed, and the wound in the peri- 
naaum was healing rapidly. No urine escaped from the old 
wound, near the anus, after the operation. A few days after 
this, he passed a full stream, a few drops only escaping through 
the perinseum, which was rapidly granulating. 

He shortly afterwards left the Hospital, but returned from 
time to time, during the following five or six months, to have 
an instrument passed. His recovery, so far as I know, was 
complete. 

Case CXXXIY. — Traumatic Stricture of Urethra. 
Perineal Section. Recovery. — July, 1863. A tall, thin, 
delicate boy, 16 years of age, tri^^ped, while walking on the top 
of a fence, and came down astride of it, striking the peri- 
nseum, and producing a rupture of the urethra. At first, there 
was a bloody discharge from the urethra, and retention of urine, 
which was relieved, at the time, by the use of a catheter. The 
next four months were passed in great suffering, and with fre- 
quent attacks of retention of urine. In January, 1864, six. 
months after the occurrence of the accident, the retention be- 
came complete ; and an operation was found necessary to 
relieve him. A distinguished practitioner was sent for from a 
distance, who cut down upon the urethra in the perinseum, 
having first introduced a catheter into the penis as far as 
possible. The urethra was reached at the point where the 
obstruction commenced, but could not be traced farther ; and, 
although an elastic catheter was introduced into a passage 
which seemed to communicate with the bladder, it was after- 
wards found not to reach that organ. From that time until 
I saw him, six weeks after, he had periodical returns of reten- 
tion about once a week, which were relieved by the escape of 
a small portion of solid matter, followed by a jet of urine. 
Improvement for about a week followed ; but, at the end of 
that time, the retention again occurred. The urine showed a 
constant tendency to escape by the perinasum, unless prevented 
by closing the orifice by the finger. 

After watching the case for a week, during which time he 
had an attack of complete retention for eight or ten hours, 



PERINEAL SECTION. 237 

which was only relieved by opium and ether, I finally operated 
on him on the 8th of March, 1864. 

He was placed in a strong light, and fully etherized : a capil- 
lary bougie was passed into the urethra, and the end of it 
appeared at once through the opening in the perinosum. The 
dissection was now made upwards towards the spot at which 
the bougie escaped from the urethra, in hopes of finding a con- 
tinuation of the passage in its vicinity. On dissecting to this 
spot, which was underneath the scrotum, near its root, no trace 
of the inferior portion of the urethra could be discovered. 
After exploring for a time with a hooked probe, a small opening 
was detected at the side of the other, but not in a direct line 
with it. Into this, a second capillary bougie was passed, which 
evidently penetrated to the bladder. The whole length of this 
passage was now gradually laid open, being through a solid ad- 
ventitious deposit. There was no possibility of passing a 
probe, even at the side of the bougie, until arriving nearly at 
the neck of the bladder ; the urethra being, in fact, constricted 
throughout the whole perineal portion. A probe was now 
passed into the bladder ; and a catheter of medium size, being 
first passed into the meatus, was carried by the side of the 
probe into the bladder. On withdrawing the probe, a quantity 
of calcareous matter escaped. In the course of the night, a 
stoppage took place, which could not be relieved either by using 
the stylet of the catheter or by injections ; and the urine began 
again to escape by the opening in the perinsgum. On passing the 
finger into the rectum, the bladder was found to be half full of 
semi-solid matter, feeling like a bag of putty. This proved to 
be a phosphatic deposit, which had probably been for a long 
time collecting, owing to the extreme narrowness of the passage 
through which the water trickled. The elastic instrument was 
therefore removed, being dragged away with some slight diffi- 
culty, owing to the calcareous substance which adhered to it. 
This was replaced, fortunately without much difficulty, by an 
S-shaped silver catheter. The bladder was syringed out twice 
a day with water, and some of the phosphatic substance 
brought away at each injection. This catheter became stopped 
on the following day, and had to be taken out and replaced, 



238 GENITO-URINARY ORGANS. 

which was effected under ether. He ultimately recovered, re- 
quiring the occasional use of the instrument to maintain the 
free passage of the canal. 

Case CXXXY. — Stricture of Urethra of twenty years' 
standing. Fistulm 171 Perineo. Perineal Section. — A man, 
56 years of age, thin, pale, and of miserable aspect, entered the 
Hospital in March, 1865, with strictures of the urethra of twen- 
ty years' standing. The urine trickled away in drops or a fine 
stream, and no instrument could be passed into the bladder. 
Some years before, he had a perineal fistula, which, after 
treatment, closed ; the urine resuming its natural channel. His 
strictures had, however, continued to grow worse. After a 
trial of several weeks, a capillary bougie was passed without 
violence through the first stricture, which was just in front of 
the scrotum. It was left for half an hour every day in the 
stricture, gradually dilating it. A second stricture was soon dis- 
covered opposite the middle of the perinseum, where a callosity 
could be felt of the size of a marble. The bougie was finally 
passed through this obstruction also into the bladder. Despair- 
ing of getting in any larger instrument as a guide, as the intro- 
duction of this small one had already occupied several weeks, I 
determined to operate. A free incision was made, in the usual 
manner, in the perinasum ; and a long and patient dissection 
performed before the urethra could be discovered, the bougie, 
from its smallness and flexibility, scarcely serving as a guide to 
the touch. The urethra was found to have been pushed to one 
side of the median line by inflammatory exudation. It was 
opened at the strictured part for the length of about half an 
inch, after which it admitted a No. 8 elastic catheter from the 
wound into the bladder. To divide the other stricture behind 
the scrotum, a director was carried up from the wound to the 
stricture, and on it a concealed knife was passed, and the con- 
striction with some difficulty divided ; there being a disposition 
to push the stricture in front of the knife, owing to its extreme 
toughness. A No. 6 elastic catheter was now introduced into 
the meatus, and passed into the bladder, though with difficulty; 
for the external stricture grasped it with some force. The 



PERINEAL SECTION. 239 

patient was placed in bed, and an elastic tube attached to the 
catheter to convey the urine into a receptacle placed for it be- 
neath the bed. For the first time for many years, the water 
flowed freely from the bladder. On the following day, the 
stricture had already, from absorption, so far relaxed its hold 
upon the instrument, as to admit of its easy withdrawal, and 
the introduction of a larger one ; a proceeding rendered neces- 
sary also from the obstruction of the eyes of the first one by the 
mucus of the bladder. For the same reason, it was ultimately 
necessary to substitute an S-shaped silver catheter for the elas- 
tic one ; after which the obstruction did not recur, and the man 
made a good recovery. 

Case CXXXVI. — Traumatic Stricture. Perineal Sec- 
tion. Recovery. — June, 1865, a man, aged 49, entered the 
Hospital. Three years previously, he fell a distance of eight 
feet, coming down astride of a beam. This was soon followed 
by abscesses, which resulted in urinary fistul^e. On entrance, 
the scrotum and integument of penis were greatly swollen and 
(Edematous. At the middle portion of urethra, through the 
scrotum, a hard tumor, the size of a goose's Qgg^ could be 
detected. The urine passed only in drops. A capillary bougie 
could be made to enter with difficulty into the bladder. 

Perineal section and the operation for phymosis were per- 
formed about two weeks after coming to the Hospital ; and, in 
a little more than three weeks after the operation, the patient 
was discharged well, the scrotum and penis having resumed 
their natural dimensions, and the urethra being thoroughly per- 
vious. 

Case CXXXVH. — Traumatic Stricture. Perineal Sec- 
tion. Recovery. — April, 1865. A laborer, two years before, 
received an injury to the perinaeum, which was succeeded by a 
stricture of the urethra. Subsequently, fistulous openings ap- 
peared in the perinaeum, which communicated with the urethra : 
these, however, healed. On entering the Hospital, it was found 
that the urine escaped from the meatus in drops, while the 
greater portion made its way through fistulas on the under aspect 



240 GENITO-URINARY ORGANS. 

of the penis, and that there were several strictures ; one near 
the meatus, and the others in the membranous portion of the 
urethra. The penis was oedematous. 

Perineal section and the operation for phymosis were per- 
formed, and the patient discharged nearly well, one month 
after the operation, and two months after being admitted. 

Case CXXXVIII. — Traumatic Stricture, Perineal 
Section, Recovery. — March 13, 1861. A laborer, aged 53, 
received, about three months before, a blow in the peringeum, 
where an abscess formed, and, twenty-four hours after injury, 
broke, discharging blood and urine ; leaving a fistulous open- 
ing, through which patient voided his water for two months 
prior to his coming to the Hospital. 

On examination, an impermeable stricture was found about 
one inch anterior to the triangular ligament. The fistulous open- 
ing in the perinaeum admitted a probe for the distance of an inch. 

March 23d. Perineal section was performed, and the stricture 
divided. In six weeks, the urine was passed through meatus, 
the wound healed, and the patient discharged well. The con- 
valescence in this case was protracted, the patient having re- 
peated attacks of erysipelatous inflammation and hemorrhage. 



DISEASES OF THE PROSTATE GLAND. 

The affections of the prostate gland are of great importance, 
and require quite as much delicacy in their treatment as do stric- 
tures of the urethra. Stealing on gradually in persons about 
sixty years of age, they do not often require the assistance 
of a surgeon until almost complete stoppage of water has taken 
place. It will then be found, that the patient, for some time 
previously, has passed his water very frequently, and that finally 
it has begun to dribble away from him insensibly : on passing 
the catheter, a large quantity of fetid urine is evacuated ; and it 
will at once be seen, that, for a long time, the bladder has been 
but partially emptied. In most instances, the prostatic catheter 
can, with great care, be made to enter the bladder : in others, 
however, the passage has been rendered tortuous by the en- 



WOUND OF THE BLADDER. 241 

largement of the third lobe of the prostate, and great care is 
required, or mischief will be done with the instrument. In 
these cases, I have managed best with a French gum-elastic 
catheter, terminated with an almost capillary point, and having 
the eye, or aperture in it, at about two inches distance from 
the termination. This may be introduced as far as the obstruc- 
tion, with a stylet within it : by a sudden motion, it may then 
be shot off from the stylet, and carried into the bladder. If 
carefully withdra^\n, after remaining in place for some hours, 
it will generally retain the curvature of the tortuous passage. 
Where there is much pain or irritation from the introduction 
of the instrument, it had better be left in the bladder for the 
greater part of the twenty-four hours. If these causes do not 
exist, the water may be drawn off two or three times a day. 
Most patients, after having a paroxysm like the above, are 
relieved, and things go on for a time as usual : in others, 
where the pain and suffering has been very great, secondary 
symptoms come on ; and, just as the patient seems to have got 
through his difficulties, a cerebral affection supervenes, and 
he dies with all the symptoms of uraemia. Where blood is 
thrown out into the bladder, and no urine passes on the intro- 
duction of the catheter, an injection of water may be made ; and, 
after a day or two, the coagula become dissolved, and pass off 
without difficulty. Cases, which at first look very formidable, 
often turn out favorably , even in persons of quite an advanced 



"WOUND OF THE BLADDER. 

Case CXXXIX. — Remarhahle Case of a Wound of the 
Bladder. — A young, vigorous, and brave officer was struck 
by a ball, which passed directly through the pelvis, just be- 
hind the hip joint, penetrating the bladder, the urine escaping 
from both openings of the wound. An examination by the 
rectum, as reported by the patient, revealed the fact that the 
left lobe of the prostate had been carried away. A catheter 
was introduced and kept in the bladder, and the urine allowed 
to pass through it during the treatment. Inflammation took 
place in the course of the urethra ; and an abscess formed in 

31 



242 GENITO-UEINARY ORGANS. 

front of the scrotum, breaking there, leaving the urethra open 
for a space of nearly two inches. At the time of the reception 
of the wound, there was a sense of numbness produced in both 
lower extremities. After a long and tedious confinement, he 
regained fair health, having an aperture in front of the scrotum, 
through w^hich the urine passed when the bladder was evacu- 
ated ; the recovery being in other respects good, considering 
the gravity of the injury. He returned to his post, and took 
part in an engagement, five or six months afterwards. Shortly 
after this, he consulted me ; being nervous on account of a 
want of power which he felt in the lower extremities, and which 
he feared might lead to paralysis. These symptoms I attributed 
to his riding on horseback. On examination of the wound 
made by the ball, I found the scars on either side of the pelvis 
in a healthy condition ; and, on examining the neck of the 
bladder, a bridle could be felt in the rectum against the left lobe 
of the prostate, where the injury had apparently been. The 
aperture in front of the scrotum was large, and a great part of 
the urine escaped through it during micturition ; but there was 
perfect control over the neck of the bladder. 

This case is a very interesting one, from the fact of there 
being so serious an injury of the pelvis and bladder, urine pass- 
ing out fi'om both openings of the wound, followed by good 
recovery. 

VESICO-RECTAL FISTULA. 

Case CXL. — Communication between the Bladder and 
Rectum^ resulting jyrohahly from Ulceration, — Dec. 12, 
1864, a man about 35 years of age consulted me on account of 
the following diseased condition of the bladder, which I put on 
record on account of its rarity. He said, that, for a month, he 
had passed no urine, but only a white, milky fluid, per anum, 
in quantity of about a table-spoonful, when he strained at stool. 
On farther questioning, however, I found that, three times a 
day, he was in the habit of going to the water-closet, and dis- 
charging from the rectum a large quantity of fluid, followed by 
a solid operation. He said that he had suffered for the past two 
years from inflammation of the bladder, caused, as he supposed, 



CANCER OF PwECTmi. 243 

by assisting at the confinement of his wife, whom he held dur- 
ing the whole night, while she was struggling with the pains of 
labor. This he did much against his inclination. Ever since 
that time, he had difficulty in passing his water, which was dis- 
charged quite frequently, and mixed with mucus. 

I passed an elastic catheter into the bladder, and drew off 
about half an ounce of fetid urine, mixed with pus : some blood 
followed the withdrawal of the instrument. A rectal examina- 
tion disclosed nothing abnormal ; but the finger could not reach 
high enough to detect the opening into the bladder. It was very 
evident, however, that the case was one of long-continued in- 
flammation, with ulceration of the bladder, ending in perforation 
into the rectum. I forbear giving the treatment, as there was 
evidently but little to be done. 

The patient was excessively pale and emaciated, and had the 
aspect of a man whose case would be likely to terminate un- 
favorably. 

Cancer of Eectibi. — Case CXLI. — Scirrhous Tumor 
of the Mectum and Bladder. — ^A gentleman, 56 years old, 
consulted me, in 1849, on account of retention of urine. He 
was operated upon for the piles nineteen years before ; and, at 
that time, a small hard tumor was discovered near the anus, 
which he declined having interfered with. Afterwards, he occa- 
sionally had attacks of pain in the bowels, and indigestion, but 
never any serious symptoms in the rectum. He always had 
diarrhoea. 

An examination was attempted per anum ; and it was found 
that the rectum was obstructed by a scirrhous mass, which pre- 
vented the introduction even of the little finger. The retention 
was gradually overcome by the use of the catheter, and the pa- 
tient had moderately good health during the summer. The 
next fall, I was called to him on account of a second retention, 
which gave way to remedies, without the use of the catheter. 
It was, however, shortly foUowed by general anasarca ; and he 
gradually sank, exhausted. 

At the autopsy, the last four inches of the rectum were found 
pervaded by a scirrhous mass, leaving in tlie centre a narrow 



244 GENITO-UEINARY ORGANS. 

pathway for the feces. The disease had extended to the blad- 
der and urethra, and apparently implicated the middle lobe of 
the prostate gland, which projected into the bladder, and occu- 
pied about a third of its cavity. 

Owing to the loose state of the bowels, the patient had been 
able to live nineteen years with this tumor, and had suffered but 
little inconvenience from it ; and, in fact, was not made aware 
of its existence by any pain or other sensation, except an occa- 
sional irritation of the skin in the neighborhood, the result of 
the imperfect manner in which the evacuations were controlled. 

The left kidney was in a high state of inflammation, and there 
was some purulent deposit in its pelvis : the ureter was not 
extraordinarily distended. 

It might be stated, that, during the last week of his life, he 
refused food entirely, on account of the difficulty and pain in 
swallowing, caused by an inflammation in the fauces. Very 
severe hiccough ensued, which was mitigated, and the last part 
of his life made easy, by the occasional inhalation of ether. 

Case CXLII. — Enormous Cancerous Disease of Exter- 
nal Genital Organs, Removal, — A laborer, aged 36 years, 
entered the Hospital in May, 1865. Three years previously he 
had an ulcer on the penis, which was soon foDowed by inflam- 
mation of the left testicle. He received no treatment until 
October, 1864, when the diseased testicle having attained great 
size, was removed by some surgeon in the southern portion of 
the country. 

In about a month after this operation, a hard, gray-colored 
tumor formed within the lips of the wound. This was cauter- 
ized, but continued to increase in size rapidly. It presented the 
appearance of an irregular mass, about the size of a very large 
tomato, being at least ten inches in circumference, having a 
granular, fungous appearance. It enveloped the left side of the 
scrotum and the pubes, and implicated the penis. There was 
a fetid discharge, and occasionally hemorrhage, but never much 
pain. His mother had, at the time of her death, a " rose 
cancer." He desired an operation, although informed that it 
would be only palliative. 



INDURATED TIBIOR OF PENIS. 245 

May 10, 1865, lie was etherized. A ligature was first passed 
through that portion of the tumor situated above the pubes, and 
drawn up firmly. The remainder of the tumor was then dis- 
sected and torn from its adhesions, and caustic potash applied 
to the base. Several bleeding vessels were tied, and the edges 
of the wound were brouo'ht tooether with sutures. 

This was a most desperate case of disease, in which hardly any 
operation seemed available : the diseased mass was almost a foot 
in circumference, and the integuments of two-thirds of the penis 
implicated. The mass in the groin, in the course of the sper- 
matic cord, descended so deeply that the only fair way of con- 
trolling the hemorrhage seemed to be to enclose the whole base 
of the growth in a ligature. The patient left the Hospital in 
about four weeks after the operation with a wound of the size 
of a dollar, and able to move about freely and to pursue his or- 
dinary avocations. The relief from the dreadful stench of the 
ulcerated mass, even if but temporary, was enough to repay him 
for the operation. Before It he was completely disabled. The 
disease returned subsequently internally, and destroyed him. 



INDURATED TUMOR OF PENIS. 

Indurated Tumor of Penis. — I have four or five times 
met with a very peculiar disease of the cavernous texture of the 
penis, which I have not seen described in any book until re- 
cently. It has generally appeared in the upper part of the 
fibrous covering of the corpora cavernosa at the root of the 
penis, and so perfectly defined, flat, and firm, as to seem like 
a foreign body implanted in the substance of the organ. Its 
edges were quite regular, with sharply defined corners, like a 
bit of broken crockery. The disease has usually appeared 
slowly, increased gradually till the induration has arrived at 
about the size of a ten-cent piece or somewhat larger, and 
then remained stationary. It has not been productive of much 
pain ; and the principal effect has been to produce an increased 
curve of the penis towards the pubes, with a degree of tension 
and uneasiness during erection. In one instance, — that of a 
gentleman about forty years of age, — the induration was lim- 



246 . GENITO-UKINARY ORGANS. 

ited to one side, and caused a deviation of the organ in that 
direction, a greater source of inconvenience than in the position 
stated above. 

The tumor is entirely free from acute inflammatory action, 
and is unlike the induration caused by the rupture of the 
cavernous tissue, which occurs in the course of venereal disease. 
This is particularly the case in the inflammation from gonorrhoea, 
which is limited to the under part or one of the sides of the 
penis, and sometimes terminates in suppuration. 

The treatment adopted consisted principally in management 
of the diet, abstinence from all excitement of the sexual organs, 
and in the local application of mercurial ointment by inunction ; 
also in the use of an ointment of the iodide of potash, and 
occasionally of leeches. These remedies, especially the mer- 
curial ointment, have seemed to have the effect of arresting the 
disease, or producing a slight diminution of it, but in only one 
instance causing the entire disappearance of the tumor : so that 
I have almost been led to the conclusion that there may be a 
slight deposit of calcareous matter in it. In none of the cases 
met with has an operation seemed to be necessary. 

Having made a statement of the above facts to the Boston 
Society for Medical Improvement, about ten or fifteen years 
since, for the purpose of eliciting information, my attention was 
drawn, by a medical gentleman, to a paper published in the 
"London Lancet," about that time, giving a number of cases, 
but attributing the origin of the disease to former venereal affec- 
tions ; at least, in most of the cases adduced, the patients had 
been more or less addicted, in the course of their lives, to sexual 
irregularities. 

This disease is also noticed by Dr. Gross in his " Surgery," 
published in 1859, where he refers to a case of indurated tumor, 
in the pectiniform septum, removed by an operation. 

Case CXLIII. — Indurated Tumor of Penis. — A gentle- 
man 56 years of age, well-formed and in good health, with the 
exception of a prolapsus of the anus, applied to me on account 
of a trouble in the penis. He said that, during erection, the 
glans crooked backwards on the dorsum ; also, that the sexual 



INDURATED TUMOR OF PENIS. 24V 

powers were much diminished. On examination, I found at tlie 
back and root of the penis, partly hidden by the skin, an indu- 
ration situated in the corpora cavernosa, extending quite across, 
and of a depth of about an inch. It felt almost like a bit of 
wood under the fibrous sheath of the penis. He said that it 
had existed about two years, gradually extending from behind 
forwards. There was no pain in it, nor sensation on handling 
it. I could not discover any symptom of trouble in the ure- 
thra, prostate, bladder, or kidneys. 

I advised him to use a cold enema daily for the prolapsus, to 
rub the tumor with an ointment of the submuriate of mercury 
and the iodide of potassium, to avoid excitement of the organs, 
to use no stimulant, and restrict himself principally to a vege- 
table diet ; also to take internally the iodide of potassium, three 
grains, twice a day. Under this treatment, the tumor slowly 
decreased in size, but did not disappear entirely. 

Case CXLIV. — Indurated Tumor in the Penis. — In the 
previous case, the induration was situated on the dorsum of the 
penis, near its root, and in the immediate vicinity of the pubes. 
In the present instance, it was situated near the extremity of 
the organ, and in close proximity to the glans. The gentleman 
was advanced in life, somewhat gouty or rheumatic of habit, 
had been troubled with sciatica, and at one time dyspeptic. 
He had never suffered from any form of venereal disease. 
When I saw him, he was in a very good state of health. 
His attention was first drawn to this affection, from his penis 
becoming distorted during erection, being turned a little to 
one side. This was attended with a slight degree of uneasi- 
ness, and with an unnatural hardness of the organ at the point 
indicated. On examination, I found on the back of the penis, 
near the glans, and somewhat to the left side, a distinctly 
marked induration, which felt almost like a foreign body, 
situated beneath the skin, in the fibrous tissue of the corpus 
cavernosum. It was quite angular ; and, when seized with the 
fingers, was found to be partially movable in the surrounding 
parts. There was no appearance of inflammation, nor any 
tenderness on pressure. I advised him to apply, twice a day, 



248 GENITO-URINARY ORGANS. 

mercurial ointment over the induration, first bathing the part 
with warm water. This course was followed for about a month, 
when the use of the ointment was suspended on account of a 
slight irritation of the skin. This soon subsided, and an oint- 
ment of iodide of potassium was substituted for the mercurial 
ointment. He was also advised to take no wine, and not to 
ride on horseback, both of which he was in the habit of doing. 
It may be stated that there was no disease of the urinary or- 
gans. The patient followed this course for about a year, sus- 
pending, from time to time, the use of remedies, for eight or 
ten days together. He used, for the most part, the ointment 
of iodide of potassium, rarely the mercurial. The disease 
gradually yielded to a certain extent, the sharp outline of the 
induration disappearing, leaving only an undefined hardness, 
which was rather difi&cult to detect. At this period, I advised 
him to suspend treatment, but to follow out the precautions 
which I had pointed out. The unpleasant symptoms which at 
first attended the disease had disappeared. 

The history of this case is very similar to that of others, — 
the mitigation of the symptoms under treatment ; but in nearly 
all there was still a persistence of some induration, in spite of 
remedies. I have never seen it assume a malignant form, 
the fear of which patients generally have in their minds, nor 
could any of the cases be traced to a venereal origin. 

Since writing the above, the patient consulted me for another 
affection ; and I found that the induration had completely dis- 
appeared. 

Tumors of Spermatic Cord. — Case CXLY. — Adipose 
Ttwtors of the Spermatic Cord. Removal, Recovery. — 
November, 1849. A married man, 56 years old, twenty years 
before produced an inguinal hernia on the right side, by a strain. 
It was of the size of chestnut, and easily reducible. He had 
always been liable to the recurrence of the hernia since, and 
wore a truss. 

In 1837, he perceived a small swelling, or tumor, at the lower 
part of the scrotum, of a globular form, hard, movable, not 
tender. The testicle, he thought, could be felt below. This 



TU3I0RS OF SPERMATIC COED. 249 

tumor increased until it had attained the size of an orange, 
and then ceased to enlarge. 

Nine years after the appearance of the first tumor, a second 
one was detected above it ; and three others have since been 
discovered. He had been examined by a number of surgeons, 
and the tumor variously pronounced to be a hydrocele, disease 
of the testicle, omental hernia, &c. 

On examination, it presented the following appearances : The 
scrotum was the size of a child's head at birth, the increase 
being evidently on the right side. It contained, apparently, 
several tumors, more or less connected. One, at the lower 
part, of the size of the testicle, and in w^iich pressure caused 
the peculiar pain produced by injury to that organ ; above this, 
a tumor of the size of an orange, quite hard and insensible ; 
still higher, two large and two small tumors, the latter being in 
the vicinity of the inguinal ring. An indistinct feeling of fluc- 
tuation pervaded the whole of the mass, which was pressed up 
against the orifice of the inguinal canal, and completely cov- 
ered it. 

On dragging it down, and embracing the integuments be- 
tween the thumb and forefinger, the spermatic cord could be 
distinctly perceived passing out from the ring ; but, on the most 
careful examination, no prolongation of the tumor into the ab- 
domen was discovered. On causing the patient to cough, a por- 
tion of intestine was felt to force itself down into the scrotum, 
and immediately recede. The question of diagnosis seemed to 
regard : 1st, An omental hernia ; 2d, A disease of the testicle; 
3d, Some tumor of rare occurrence. 

The objection to the former was, that there seemed to be no 
connection between the tumor and the abdomen ; and, although 
it is known, that, in some cases, from the effects of pressure, the 
connection in old omental hernia with the abdominal cavity is cut 
off, this is not of very frequent occurrence. To the supposition 
of its being a diseased testicle, the small tumor at the lower 
part of the scrotum, of the apparent size and sensibility of that 
organ, could be objected. My own impressions were in favor 
of the third view of the case, and therefore I advised him to 
have an exploratory incision made ; and, if it was found that 

32 



250 GENITO-UEINARY ORGANS. 

the operation could not be terminated without great risk to life, 
that the wound should be closed without proceeding further. 

This being consented to, the patient was etherized, and an 
incision made through the integuments of the scrotum, exposing 
the middle lobe of the tumor ; but the diagnosis was not eluci- 
dated by cutting into this. The lower lobe was then removed ; 
the testicle being incorporated in it, apparently healthy, though 
smaller than natural. In the dissection of the remainins^ tu- 
mors, nearer the inguinal ring, the hernial sac was unavoidably 
cut into, being intimately connected with them. No intestine 
appeared, careful compression being made on the inguinal canal 
during this latter part of the operation. 

The recovery was perfect, after a smart attack of consti- 
tutional irritation ; the inguinal ring being plugged by the re- 
mains of the inflamed and thickened sac. 

The tumors, on careful examination, were found to have a 
fatty structure, and embraced the spermatic cord, — the vas 
deferens being traced, in its whole length, passing through the 
centre of the mass. 

One or two instances of similar tumors are given by authori- 
ties, but none apparently of so large a size. 

PHIMOSIS, 

The operation for phimosis has been variously performed. 
The common method is to pull forward the skin, press back the 
glans, and then remove a circular piece from the end of the pre- 
puce. On letting go the part, the skin recedes, leaving the 
mucous membrane still constricted, and often with a ring of in- 
tegument attached to it. This is slit up longitudinally on the 
upper side, and the edges of the skin and mucous membrane 
brought together by a series of sutures placed around the whole 
circumference of the oro^an. The old method consisted in sim- 
ply slitting up the prepuce upon its dorsal aspect, and allowing 
the integument to recede on either side. This operation, in 
many cases, answers the purpose, although it leaves a rather 
unseemly flap of loose skin. The operation first described, in 
some cases, does perfectly well ; but, almost always, there is 



HYDROCELE. 251 

an excessively sore spot at the point where the feniim is divi- 
ded, taking a long time to heal, and attended by much irritation. 
All the benefits of the operation may be secured by the follow- 
ing procedure. The front or dorsal part of the prepuce Is 
seized by forceps, placed obliquely upon it, so as to take up a 
triangular portion of the tissues, covering the glans ; the skin 
behind, or tliat continuous with the frtenum, being left un- 
grasped by the jaws of the instrument. The portion protruding 
beyond the forceps is cut away with scissors. The same end 
may be attained by making the skin tense, by introducing one 
blade of the forceps inside the prepuce and the other outside, 
and removing an apron-like portion in front ; care being taken 
to divide the mucous membrane well down towards the base of 
the glans, as a failure in this part of the operation is one 
of the most fertile sources of strano'ulation. The edo;es of the 
wound are then nicely adjusted by means of many sutures 
taken very near the margin. It will be understood, that, in 
this latter operation, the skin behind is not interfered with. 

The effect of phimosis is to act as a place of deposit for con- 
tagious secretions. In many cases which I have seen, in young 
persons, it has appeared also to have retarded the growth of 
the organ. In children, we often find the prepuce adherent to 
the glans, sometimes so firmly as to render it impossible to de- 
stroy the adhesions ; in which case, there is nothing to be done 
but to cut the skin, and draw it backwards. Generally, how- 
ever, after slitting up the prepuce in front, the mucous surfaces 
can be easily separated from each other by means of a probe. 



HYDROCELE. 

I shall allude to this common disease very briefly. The 
favorite treatment of late years has been by the injection of 
tincture of iodine. A drachm of the tincture, or, what is per- 
haps better, the compound tincture, of iodine, as it does not 
precipitate, diluted with three parts of water, is thrown into the 
sac, and left there. This treatment is, however, very uncertain. 
I have tried the seton, but have seen much Inflammation pro- 
duced by it; and in one case, hemorrhage, from the ulceration 



252 GENITO-UEINARY ORGANS. 

caused by it, cutting off a good-sized vessel. Incision is apt to 
be followed by suppurative inflammation and a tedious conva- 
lescence. In one or two instances in which I have lately prac- 
tised it after other means had failed, I found, attached to the 
testicle, numerous cystic growths containing spermatozoa, which 
Mr. Curling describes as having found in an encysted hydrocele 
attached to the epididymis. As a general rule, I have found 
that the wealthier classes in life prefer the palliative operation 
of tapping. The laboring classes, who are more inconvenienced 
by it in their vocations, prefer the radical cure. Before operat- 
ing, it is always necessary to look for the translucency of the 
tumor, by sunlight if possible. The operation of tapping is 
best done with a small trocar, thrust in quickly ; the point being 
directed obliquely upwards, as the testicle is usually at the back 
part of the scrotum. 

HEMATOCELE. 

Case CXLVI. — Hcematocele. Extirpation of Testicle, 
— This patient had carried a tumor, of unknown origin, for 
nineteen years. When seen, it was of the size of a cocoa-nut ; 
firm, without fluctuation, and presenting an inflamed spot upon 
its anterior aspect. Being considered a tumor of the testicle, its 
extirpation was advised and practised. The sac, which was not 
punctured during the operation, was subsequently laid open, 
and gave issue to a dirty-colored fluid. The testicle, after the 
removal, was found flattened and w^asted on the posterior face 
of the sac. The tunica vaginalis was thickened to nearly a 
quarter of an inch, its interior lined with coagulated lymph, 
and distended so much as to hold a pint. The recovery was 
perfect in two weeks ; and, although there was a mistake in the 
diagnosis, the operation performed was the best for the patient, 
as the process of granulation, in so thickened a sac, must neces- 
sarily have been very tardy, and the testicle was no longer of 
any efliciency. 

The difliculty of diagnosis was increased by the enlargement 
of the other testicle, which had within a year attained double 
its natural size, was much flattened, and evidently had no 



H^3IATOCELE. 253 

water external to it. Both the patient and his physician in- 
sisted that the disease of the other testicle commenced in the 
same manner ; and the latter stated that he had often examined 
it with the view of detecting fluid in the tunica vaginalis, but 
never could discern any. 

Case CXLYII. — Case of Hcematocele, resembling Dis- 
ease of the Testis. Removal. — In May, 1865, the following 
case of difficult diagnosis came under my care at the Hospital. 

The patient was a colored man, about 35 years old, of large 
powerful build, belonging to the navy. Seventeen years be- 
fore, he had received a blow upon the testicle from the fall 
of a powder box. The testicle swelled until it was twice as large 
as natural, and afterwards did not diminish in size. In March, 
1865, he had an attack of intermittent fever, attended with 
great swelling of the testicle, and excessive pain in it. The pain 
was so great when he entered the Hospital, that he hoped to 
have the testicle removed the same day. For the farther inves- 
tigation of the case, however, I decided to place him under treat- 
ment for a short time. He was put in bed, on a light diet, and 
large laudanum poultices were kept constantly applied to the 
scrotum : opiates were given at night. Under this treatment, 
in three days, great improvement took place ; the pain was 
much relieved ; and it was possible to handle the organ. On 
examination of the parts, the cord was found quite healthy ; 
the tumor of the scrotum was nearly globular in form, smooth 
and elastic, such as might be presented by a greatly enlarged 
testicle ; no feeling of fluid could be detected. The skin moved 
freely over all the tumor, except at the back part, where there 
seemed to be a projection from the main mass of a different 
character ; the skin here being adherent, and the subjacent tissue 
giving a pasty sensation to the flnger. 

Being in doubt as to the nature of the disease, I informed 
him, that, after exposing the surface of the tumor, I should ex- 
plore it before proceeding to extirpation. He was therefore 
etherized, and an incision made in the scrotum, over the front 
part of the tumor. A second incision, at the lower part of the 
scrotum, exposed a small portion of the healthy structure of the 



254 GENITO-UKINARY ORGANS. 

testicle. An incision was then made deep into the tumor above, 
by which a sac, nearly three-quarters of an inch in thickness, 
was opened, giving vent to a little bloody fluid. A fibrinous 
mass was found in the sac. The case was at once shown to be 
one of old hasmatocele, and its removal was proceeded with. 
The projection behind was a cyst filled with fluid, which had 
been the seat of recent inflammatory action. The skin of the 
scrotum was here so adherent, that it was removed with the 
tumor. The testicle, as in the preceding case, was much dimin- 
ished in size, and so displaced and compressed that its functions 
must have been entirely suspended. The left scrotal cavity 
was the seat of a hydrocele, which, however, was of recent 
development, and probably dependent upon the acute attack of 
the other side. 

VARICOCELE. 

Many methods have been suggested for the cure of varicocele, 
or enlargement of the spermatic veins. Breschet's method, 
with the screw-clamp, is almost insupportably painful ; while 
that of Ricord, which is now perhaps the favorite one, consists 
simply in cutting across the packet of veins with a ligature. I 
have tried both these plans, as well as that by removing a por- 
tion of the scrotum ; or, in cases where it has been much elon- 
gated, by producing adhesions of its sides by means of sutures. 

The following operation for the relief of varicocele, which I 
have successfully performed in from sixty to seventy cases, and 
which is I believe peculiar, seems to me to be the simplest and 
most effectual. The vas deferens is first separated from the 
vascular part of the cord, and is kept out of the way by an 
assistant. A longitudinal incision of about two inches in 
length is next made in the scrotum down upon the bundle of 
veins, which is then seized with the forceps, drawn out, and, by 
a few touches of the knife, separated from the adhering tissues. 
Two strong ligatures are now passed above and below the mass 
of enlarged veins, and firmly tied, so as to include between them 
as much of the diseased tissue as possible. The strangulated 
veins, which at once shrink into a very small compass, are now 



VARICOCELE. 255 

allowed to recede into the wound, which, by the contraction of 
the scrotum, becomes reduced to a comparatively small size. 
The patient is confined to his bed, and water-dressings applied 
during the separation of the slough, which takes place in from ten 
to fourteen days. In several cases, where the scrotum has been 
elongated to double its natural length, and filled with large 
masses of veins, which would almost seem to defy any mode of 
treatment, I have operated by this method with perfect success, 
and have seen the scrotum contract within a few weeks, or at 
most a few months, to its normal size. 

I have never seen varicocele except on the left side of the 
scrotum. 

Case CXLVIII. — Yaricocele of Great Size. Operatio7i. 
Recovery. — A young man, 22 years of age, for ten years 
had more or less of a tumor in the scrotum. Finally, it 
became so large and cumbersome, and attended with so much 
pain in the loins, that he consulted me for relief. The scrotum, 
when the veins were fully distended, hung half way down the 
thigh. The left testicle was atrophied ; and its vas deferens, 
when separated from the rest of the spermatic cord, was but 
half the size of the other. The testicle was so enveloped in 
the enlarged and thickened veins, that I feared it would be diflfi- 
cult to remove the latter, without the former beino; drao^o-ed out 
with them. I therefore informed the patient that this might 
take place, as it had once before occurred to me in a similar 
instance, which made it necessary to remove the whole mass. 
He agreed to have done what was thought expedient. Being 
etherized, and the vas deferens held out of the way by an assist- 
ant, the veins were exposed as high up as possible, for fear of 
encroaching on the tunica vaginalis ; and a loop of them being 
drawn out, assisted by a few strokes of the bistoury, a double 
ligature was passed under, and tied above and below. The 
scrotum being too long, a large piece of it was excised. The 
whole wound, with the exception of where the ligatures and 
tumor formed by the tied -up veins protruded, was closed by 
sutures. A cold-water compress was placed over the wound. 

A considerable amount of inflammation followed this com- 



256 GENITO-UEINARY ORGANS. 

plicated operation. At the end of four days, the sutures were 
withdrawn, and most of the slough of the veins cut off. 
The wound was dressed with a poultice. An abscess formed 
low down at the back of the scrotum, and required the bistoury. 
After this, he gradually recovered ; and left the Hospital in three 
weeks, with a small, healthy, granulating wound. The scrotum, 
from the size of an orange, was reduced to that of an egg. 

I saw him, some months afterwards, entirely free from dis- 
ease, and relieved of pain. 

Case CXLIX. — Varicocele and Hydrocele. Operation. 
Recovery. — June, 1860. — A man 60 years of age had, for 
a long time, been afflicted with a varicocele and hydrocele of 
the left side of the scrotum. It caused him pain in his back, 
from the dragging on the cord. Being etherized, an incision 
was made over the cord ; the veins were drawn out, and tied in 
the usual manner. At the same time, a slight opening was 
made into the tunica vaginalis, and the serum evacuated. The 
patient did well for two or three days, when he was attacked by 
gangrene, which then, for the first time since the organization 
of the Hospital, pervaded the house, on account of the filling-up, 
with bad material, of the flats in the neighborhood. A large 
bit of the scrotum sloughed, and an abscess formed behind, 
which required evacuation. A yeast poultice was applied, and 
the patient put upon quinine and stimulants. At the end of a 
month, he was well enough to leave the Hospital ; and, a month 
afterwards, he called on me perfectly well, the varicocele and 
hydrocele being both cured. 

Case CL. — Varicocele. Operation. Recovery. — A sol- 
dier, 36 years of age, entered the Hospital, Oct. 10, 1864, for 
a large varicocele in the left side of the scrotum, which had 
troubled him for many years, but had been aggravated by the 
performance of military duty, during four months, and finally 
caused his discharge from the army. 

On the 12th of October, the veins being exposed by an in- 
cision, in the manner described above, a long, curved needle, 
armed with a double ligature, was passed between them and the 



RETAINED TESTICLE. 257 

vas deferens. The loop of the ligature being cut, and the veins 
pulled out as far as possible, the ligatures were tied above and 
below, so as to include a large mass of vessels. The whole 
was then pushed back into the scrotum, and water-dressings 
applied. On the 27th of October, part of the ligatures were 
removed with the forceps ; and, on the 29th, the rest came away. 
Oct. 31st, he left the Hospital well. 

RETAINED TESTICLE. 

Case CLI. — Testicle retained in the Groin. Removal, 
Subsequent Death of the Patient from Internal Disease^ 
apparenthj Malignant, — A gentleman, 38 years of age, con- 
sulted me in February, 1856, on account of his right testicle, 
which had never descended into the scrotum, but had been 
retained in the inguinal canal. For many years, this was no 
inconvenience to him ; but, just before he saw me, it had been 
quite tender, giving him extreme pain on the slightest pres- 
sure, extending upwards into the abdomen, and down the thigh. 
As no treatment gave relief, I performed the operation of re- 
moval. 

He was in poor health, and quite nervous, but with no appar- 
ent malignant disease. He was etherized with chloric ether, and 
the dissection conducted with the utmost caution, for fear of in- 
fringing on the abdominal cavity. The testicle was removed, 
with the tunica vaginalis, which closely embraced, and in some 
places strongly adhered to it. 

On cutting into the testicle, the structure was found to be 
completely disorganized : the upper part of its body presenting 
the aspect of an unripe apple ; in the lower was a cyst filled 
with a jelly-like material. Under the microscope, some nucle- 
ated cells were seen. 

This gentleman recovered from the operation ; but died 
suddenly a year afterwards, having suffered for some time 
previously with obscure symptoms of internal disease. 

In two other cases of testicle retained in the groin, which 
I have witnessed, the organ was invaded by encephaloid dis- 
ease. 

33 



258 FEMALE GENITO-UKINARY OEGANS. 



FEMALE GENITO^URINARY ORGANS. 

RUPTURE OF PERINEUM. 

Case CLII. — Rupture of the Perinmum. Operation, 
Cure. — I was requested, in October, 1859, to see a lady, 35 
years of age, who, five years before, had received a severe 
laceration of the perinteum, implicating the rectum about an 
inch and a half. The effect was complete incontinence of the 
feces, causing constant annoyance and suffering. 

The patient, being fully etherized, was operated upon on 
Monday, Oct. 18th, in the following manner, the position 
being the same as for lithotomy : The lacerated edges of the 
rectum were first made raw, and a quadrangular bit of integu- 
ment removed on each side of the fissure, about three-fourths 
of an inch wide, and an inch and a half long. The edges of 
the rectum were then brought together by three sutures, which 
were cut off close. Three deep sutures were inserted, with 
strong double thread, commencing about half an inch from 
the borders of the wound, and traversing its entire depth. 
These threads, being secured over bits of bougie, were made 
tight, and brought the edges of the wound well up together. 
Five superficial stitches were now passed, to adapt more per- 
fectly the edges of the skin ; and one within the vagina, to bring 
together the deep part of the wound. This being done, the 
finger was introduced into the rectum, to ascertain what resist- 
ance was likely to be made by the sphincter ani. This, which 
before the operation could not be distinguished, was now quite 
prominent, and could be hooked up by the finger, like a broad 
cord or ribbon. An incision was therefore made through the 
integument at the margin of the anus, the muscle exposed, 
and freely and carefully divided on the finger, by the scissors, 
without cutting through the mucous membrane of the rectum. 
The anus, which before this division was closed, now remained 
loose and open. A bit of lint was placed over the wound of 
the perinseum, and fixed in place by collodion, so as to serve as 



RUPTURE OF PERm^UlI. 259 

a protection from the contact of the urine. The patient was 
then placed on her side, and a large catheter with a shield to it 
introduced into the urethra, the end of which afterwards was 
attached to a bit of gutta-percha tube, which conducted the 
urine into a male urinal provided for the purpose. On recov- 
ering from the ether, she had thirty drops of laudanum admin- 
istered to her, chiefly for the purpose of checking the action of 
the bowels. The operation lasted an hour and a half, not- 
withstanding all expedition was employed. 

She passed a quiet night, and felt no pain in the wound. The 
catheter, causing some irritation, was withdrawn, and afterwards 
was introduced twice a day, with the gutta-percha tube attached, 
to prevent any contact of the urine with the edges of the wound ; 
and subsequently an ordinary female catheter of much smaller 
size, with a gutta-percha tube attached, was employed. Her 
nourishment was principally a bit of cracker, with a little 
brandy and water, two or three times a day, which she preferred 
to the juice of meat. 

On the fifth day after the operation, the wound becoming 
sore, and the sutures more or less loose, the quill sutures were 
removed, leaving the superficial ones. She had had no evacua- 
tion, but had been somewhat troubled with flatus. The water 
was drawn oflp twice a day with the catheter, and the wound kept 
clean by constant bathing with warm water, and subsequent 
protection by a little cerate, rubbed on with the finger. 

By the tenth day, all the sutures of the rectum, skin, and 
vagina were removed ; and there seemed to be a good solid 
union, with the exception of a very small aperture between 
the rectum and vagina, which still remained open, but granu- 
lating. 

On the twelfth day from the operation, she had a very large 
evacuation from the bowels, aided by an enema of warm water. 
This was effected without doing any damage to the union of the 
wound; and, on the following day, she began to pass her water 
without the use of the catheter, sat up, took food more freely, 
and was considered convalescent. 

On Nov. 5th, I made a final examination of her case. 
The aperture in the rectum was closed, so far as could be de- 



260 FEMALE GENITO-UEINARY ORGANS. 

termlned from inspection of the part by the speculum ani, and 
disclosed no fluid passing from the rectum into the vagina. 
The peringeum was strong, thick, and firm, longer than is usu- 
ally perceived in a woman who has borne children. The union 
was so good that traces of the operation were scarcely per- 
ceptible. The patient had full control of her evacuations for 
the first time in five years ; and her stomach, though a little 
dyspeptic, was in better condition than it had been for a good 
part of that time. 

The division of the sphincter ani, and the use of collodion to 
protect the external wound from the action of the urine, were, 
I think, of great advantage in producing a favorable result. 
The removal of the urine twice daily, by the catheter, with 
a gum-elastic tube attached, was also of great utility. A little 
urine only once accidentally came in contact with the wound, 
and was immediately followed by much irritation. This can be 
prevented, when the catheter is removed, by pinching up the 
gum-elastic, retaining the urine in the instrument until it is 
carried to the utensil. 

I have gone into some detail in this case, as I have felt better 
satisfied with the management of it than of any that has come 
under my observation. The use of a small glass or ivory rod, 
in place of a bougie, would, I think, be of advantage, as less 
likely to retain irritating matter. In using the quilled suture, 
I took great pains not to draw^ the stitches tighter than was ab- 
solutely necessary to bring together the deep part of the wound, 
from fear of producing partial strangulation, and consequent 
unhealthy inflammation in the intermediate integument, — an 
accident of not uncommon occurrence, as appears by recorded 
cases. The introduction of a stitch within the vagina was of 
much use in facilitating the union. 

Case CLIII. — Rupture of the Perinceum. Operation. 
Cure. — This case is condensed from the Hospital records. In the 
spring of 1864, a young woman, 20 years of age, was admitted 
to the Hospital, on account of rupture of the perinaeum. She 
stated that, four years before, she had been delivered of a male 
child, by a midwife, after a labor of forty-eight hours. When 



RUPTUEE OF PERINJEUM. 261 

she left her bed, it was discovered that the perinnsum was rup- 
tured. She was able to retain her feces, except when they were 
very liquid. She always had pain at evacuations. 

She was etherized, and placed in the position for lithotomy. 
There was found to be a partial prolapse of the uterus. The 
rupture of the perinaium involved only a part of the sphincter 
ani, leaving the recto-vaginal septum entire. A Y-shaped in- 
cision was made through the integument along the furrows just 
outside of the external labia. That portion of skhi which lay 
near the anus was dissected up, and the dissection carried back- 
wards for a distance of three-quarters of an inch upon the up- 
per surface of the sphincter. The dissection was continued 
inwards, in the line of the Y-shaped incision, so as to obtain a 
raw surface. Thus, flaps were obtained, the edges and raw 
surfaces of which could be easily approximated. Silk sutures 
were passed through these flaps, about half an inch from the 
free edges, and secured over pieces of bougie, accurately ad- 
justed on each side of the wound. The pressure thus exerted 
was in a line with the points where the sutures were introduced. 
The' edges of the flaps were held together by means of inter-, 
rupted silk sutures. The laceration was thus closed without any 
tendency towards outward traction, since no portion of the in- 
tegument of the nates was involved in the operation. 

Direction was given to pass the catheter as often as should be 
necessary, and not to allow any urine to fall upon the wound. 
A simple cold-water dressing was applied. 

On the sixth day after the operation, an examination was 
made, and it was found that there was the usual suppuration 
about the sutures. All the sutures, except one near the anus, 
were removed. There was firm union without any tension. 
Subsequently, cicatrization was complete ; and, on the eigh- 
teenth day, she was discharged from the Hospital, cured. 

Case CLIY. — Riqoture of the Perinceum and Recto-vagi- 
nal Sejytuni. Operation. Recovery. — A lady 30 years old, 
of ordinary good health, who applied to me, was confined, two 
years before, with her first child, having been forty-eight hours 
in labor. The head of the child was dropsical, and nearly 



262 FEMALE GEmTO-UEINAEY ORGANS. 

double the natural size. As it passed the external organs, 
the rupture occurred, which, however, was not detected until 
the next day. Her physician, suspecting a laceration, made 
an examination, and introduced two stitches, w^hich were inef- 
fectual in producing union. From that time, she had not been 
able to retain the contents of the bowels, which, unlike the 
previous case, were constipated instead of being relaxed. About 
six months before I saw her, having stood a long time in a 
crowd, occasionally on tiptoe, she was taken with a sense of 
distress and weight in the pelvis ; and it was found that a pro- 
lapsus of the uterus had taken place. This was an additional 
source of trouble to her, obliging her to wear a sponge for sup- 
port, and to use astringent injections. 

The operation was done much as described in the previous 
case. The hair being shaved, a surface three-quarters of an 
inch wide was exposed on each side of the laceration. The 
sides of the deep fissure in the recto-vaginal septum were dis- 
sected up (separating the rectum from the vagina), their edges 
freshened and brought together by stitches. The perinasum was 
brought together by the quilled suture, three stitches b'eing 
used, and the edges of the skin approximated nicely by means 
of four sutures with fine thread. The sphincter ani was di- 
vided on the left side as follows : The finger was introduced 
into the rectum, and the muscle hooked up upon it. A small 
aperture was made on the margin of the mucous membrane, 
distinctly exposing the muscular fibres : these were divided 
with a small pair of blunt-pointed scissors, down to the mu- 
cous membrane of the rectum, held on the finger. The anus 
now remained perfectly open and relaxed, and without the 
slio^htest traction on the stitches holdins^ it in front. The 
operation lasted half an hour, the patient being fully under 
ether. She was placed in bed, on her side, and the nurse di- 
rected to draw off the water with a catheter having an elastic 
tube attached to it, three times in the twenty-four hours, and on 
no account to allow any urine to touch the wound. 

Four days after the operation, I removed the back-stitch 
which held the quill, as suppuration had taken place around it, 
causing some pain and irritation about the anus. In other 



VESICO- VAGINAL FISTULA. 263 

respects, every thing did well, and the patient experienced no 
constitutional disturbance. The stitches in the skin were also 
cut and withdrawn, and the union appeared good. She took 
bread, tea, and broth for nourishment. Her recovery was per- 
fect. 

VESICO-VAGINAL FISTULA. 

The treatment of this affection, which had, until very recent- 
ly, been almost wholly confined to the simplest cases, has been 
lately revived in this country with remarkable success, especially 
since the publication, by Dr. Sims of New York, of a number 
of very successful cases, in which he attributed the good result 
to the employment of sutures of silver wire ; but a more ex- 
tended trial has failed to demonstrate that superiority which was 
claimed for them over silk or linen threads, and the greater 
inconvenience which attends their employment has already led 
to their abandonment by some surgeons. 

In quite a large number of operations which I have per- 
formed for vesico and urethro vaginal fistula, I have always 
used sutures of common surgeon's silk, and have had every 
reason to be satisfied with the results. 

The real improvement in this operation, and that which has 
been the means of bringing it into so general use, is the very 
free dissection of the vaginal mucous membrane from the old 
cicatricial tissue, and from the walls of the bladder : by this 
plan, the stitches are effectually relieved from tension, and the 
results are generally favorable. 

In many cases of this disease, we find the os uteri, and some- 
times the upper part of the vagina, completely obliterated ; 
causing retention of the menstrual fluid. I have watched a 
number of cases of this kind, and have always observed that 
relief is ultimately obtained, often after great suffering, by the 
formation of a fistulous opening communicating with the 
vagina, or, very rarely, with the bladder. 

Few surgical diseases are more distressing to the patient than 
vesico-vaginal fistula, and no operation better rewards the skill 
of the surgeon. It rescues the sufferer from a state in which 
existence has become a burden, and restores her once more to 
the world and to the enjoyments of social life. 



264 FEMALE GENITO-URINAKY ORGAI^S. 

Case CLV. — Vesico-vaginal Fistula. Operation. Re- 
covery. — A woman 28 years of age, mother of three chil- 
dren, was in labor four days with her last child. All her 
children were born dead. She did not perceive the injury done 
to the bladder till she began to get up from her confinement, 
twelve days afterwards, when, on examination, it was dis- 
covered that nearly all the urine escaped through a large open- 
ing in the vagina. I first saw her in November, 1860. The 
aperture in the bladder extended from an inch behind the 
pubes to the os uteri, which was ragged and irregular, having 
been involved in the injury. She had menstruated twice since 
the accident, and was rather feeble. The skin of the inside of 
the thighs was irritated by the constant passage of urine over it. 
The operation was performed in November ; the injury was re- 
ceived in the preceding February. She was placed on an 
elevated platform, constructed for this purpose, on her abdo- 
men ; the limbs being placed at right angles with the trunk. 
The mucous membrane having been freely dissected in the 
usual way, six sutures were introduced, and the whole wound 
brought nicely together : the button-suture, according to Boze- 
man's method, was not used on account of the great extent 
of the opening, otherwise it would have been employed. She 
was laid on her side, and a catheter with a gum-elastic tube 
attached to it introduced every four hours, to draw off the 
water, the tube being added to prevent any contact of urine 
with the external organs. This plan I have found preferable 
to leaving the catheter constantly in place, as it allows much 
more freedom to the patient. Every thing went on well until 
the end of a week, when, on account of the attendant's omit- 
ting to draw off the water, she passed the whole night with 
the bladder distended. This was followed by a leakage from 
the wound the next mornino^. In the course of the followino^ 
week, all the sutures were removed ; and, about the first of 
December, she left the Hospital, as she said, well, being able to 
retain her water about two hours. I saw her before she left 
town, on the 14th December. She had not menstruated since 
the operation ; and I found it difficult to decide whether the 
opening from the uterus was into the bladder or vagina. Her 



VESICO-VAGINAL FISTULA. 265 

health, however, was good, and has remained so since. In a 
similar instance, the menstrual fluid passed into the bladder, 
and escaped from the urethra without inconvenience. 

Case CLVI. — Vesico-vaginal Fistula. Cauterization, 
Relief. PhosiDhatic Calculus. Lithotrity. Relief. — A wo- 
man, aged 32, entered the Hospital March 9, 1848. Fourteen 
weeks before, she was delivered, by forceps, of a dead child, 
after a labor of four days. During this period, she was for 
the greater part of the time insensible, from the effects of nar- 
cotics. 

Two days after delivery, there was incontinence of urine, 
which flowed constantly from the vagina, never passing by the 
urethra, or collecting in the bladder. 

She did not menstruate after her labor, nor did she have any 
difliculty at the period when the menstrual secretion should 
appear. There was, however, much milk in the breasts, but 
varying in amount : she had not noticed any relation between 
the quantity secreted and the catamenial period. 

The external organs were found excoriated by the urine, 
which was constantly dribbling away. The vagina was some- 
what contracted throughout its entire length, but more espe- 
cially at about three inches from the vulva, where there was a 
very marked constriction. Behind this was a longitudinal slit, 
with callous edges, on the anterior wall of the vagina, through 
which water was seen issuins^ from the bladder. A small irre£:u- 
lar opening existed in the posterior part of the vagina near the 
situation or in the place of the os uteri, which had entirely 
disappeared in the cicatrix. 

She was thoroughly etherized with chloric ether, as it was 
found almost impossible to make the slightest examination, on 
account of the extreme sensibility of the parts. The speculum 
of Ricord was used both for the examination and the operation. 
The edges of the fistula were cauterized, so as to produce a 
slough, with the potassa cum calce, and a catheter introduced. 
This instrument, which had been made for the purpose, was 
half an inch in diameter, five inches long, with a shield an inch 
from its external orifice. 

34 



266 FEMALE GENITO-URmARY ORGANS. 

The patient suffered but little from the caustic, and no urine 
passed through the fistula for several days. It was touched 
occasionally with creosote ; and, nine days after the operation, 
no urine having passed through it for some time, the catheter 
was omitted, and she was allowed to walk about. 

A month later, she reported that no urine passed by the 
vagina. When the catheter was first omitted, the water 
dribbled away from the urethra, which from long disuse had 
apparently lost its power of retention. This power, however, 
was by degrees restored. 

On May 7th an examination was made both by the vagina 
with a speculum, and by the bladder with a catheter. The 
fistulous opening was hardly perceptible. In the bladder was 
found a calculus, apparently about the size of a chestnut. With 
a lithotrite, the stone was easily caught and crushed. On the 
following day, the fragments of the stone came away with the 
urine. They were found to be composed of the phosphate of 
lime. 

This patient remained in the Hospital until the latter part of 
May, when she had full command over the urine. During 
the whole of this time, there was no appearance of the men- 
strual secretion ; but at stated periods, at an interval of four 
weeks, an increased secretion of milk took place in the breasts. 

A year later, she called on me, and said that she had been 
well since leaving the Hospital. About three months before, 
nearly a year after her delivery, the catamenial function was 
restored, and remained regular. This must have had its exit 
at the orifice which took the place of the os uteri, and which 
undoubtedly when I first saw her was partially occluded. 

On over distention of the bladder, a small quantity of urine 
was found to escape from the vagina. An examination with 
the speculum proved that the old fistula had closed, and that 
the urine must escape from the same fissure in the uterus as the 
catamenia, showing that a vesico-uterine fistula existed. 

In quite a number of the cases of inflammation and sloughing 
of the vagina after tedious labor, which have occurred in my 
practice, the os uteri has become obliterated. The menstrual 
function, however, has not been suspended : having, in some 



VESICO-VAGmAL FISTULA. 267 

instances, found an exit through the bladder; in others, forcing 
its way into the vagina. 

Case CLVII. — Vesica -vaginal Fistula. Operation. 
Cure. Retention of Menstrual Fluid for Nine Years. 
Spontaneous Rupture into Yagina. — About the year 1846, 
I was called to see a woman, 25 years old, who had been de- 
livered of a dead child, some weeks before, after a tedious labor. 
I found that the whole vaginal portion of the bladder had 
sloughed away, leaving but the superior, and a small portion of 
the lateral walls. There were besides laro^e abscesses runnins; 
into each groin from the vagina. After a preparatory treatment 
to restore her strength, she was operated on. The bladder 
was dissected away from the vagina as far as possible, and the 
edges of it, being pared, were brought together in the usual 
manner with silk sutures. The orsran was then not more than 

o 

one-half of its original size. The operation was followed by 
complete success. 

By the previous inflammation, the os uteri had been entirely 
obliterated ; and, at each subsequent menstrual period, she 
suffered dreadfully for a number of years. No uterine tumor 
could be detected, either by the abdomen or rectum. Mne 
years afterwards, during one of these monthly attacks, a rupture 
took place in the vagina, followed by the discharge of nearly 
two quarts of menstrual fluid. This was the only appearance 
of this secretion. I saw her in 1866, eleven years after the 
rupture, and found there had been no return of the discharge. 
There had been, however, until within three years, the usual 
premonitory symptoms of the catamenial flow, but nothing more. 
She was in good flesh and strength, but had suflered from 
disturbance in the stomach and head nearly all the time. She 
consulted me, when I last saAV her, on account of profuse vom- 
iting of a colorless fluid. The bladder had performed its func- 
tions normally since the operation. The destruction of tissue 
was more extensive, and the result of the operation more suc- 
cessful, than in any other case of this kind that I have had. 

In another case, where the whole lower half of the blad- 
der was lost by sloughing, the same symptoms were manifested 



268 FEMALE GENITO-UEINARY ORGANS. 

at the catamenial periods. At one of these periods, a year 
from their commencement, the pains became violent and forcing, 
as in labor. A rupture of some part of the uterus into the 
vagina took place; and the patient was, as she states, at once 
deluged with blood, so that long-continued fainting took place, 
from which she was with difficulty recovered. The menstrual 
function has since gone on regularly. 



PROLAPSE OF THE WALLS OF VAGINA. 

The following cases illustrate the prolapse, or hernia, of the 
bladder into the vagina, not a very common affection. It is 
usually caused by a straining effort, acting upon the relaxed 
walls of the vagina, and must be distinguished from prolapse 
of the mucous membrane of that passage, and from cystic 
tumors arising in its walls. When the tumor formed by the 
bladder is of large size, it is the source of great inconvenience 
in walking, and interferes with micturition. 

Case CLVIII. — Prolapsus of the Bladder and Anterior 
Walls of the Vagina, simulating a Tumor. — In September, 
1863, a young woman, 25 years of age, consulted me in regard 
to a protrusion from the external organs, which interfered with 
locomotion. She had been married at seventeen, and was the 
mother of five children. The tumor was not noticed until after 
the birth of her last child. Her general health was good. 

A large fold of the anterior wall of the vagina was found 
hanging down just within the labia. The os uteri was slightly 
enlarged ; otherwise the uterus was normal. Elevating that 
organ had no effect upon the tumor. A catheter, passed into 
the bladder, could be made to enter the tumor, by reversing its 
beak. 

I introduced a horseshoe pessary, with immediate relief, so 
that she was enabled to walk home, a greater distance than she 
had previously walked since her confinement. This exertion, 
however, caused a slight hemorrhage, so that I thought it best 
to remove the pessary after two days. Subsequently she 
learned to introduce it herself, and wore it with relief. 



TUMOR OF MONS VENERIS. 269 

Case CLIX. — Prolapsus of the Bladder, simulating 
Cystic Tumor. Formation of a Fistula. — In September, 
1861, I was requested to see a lady, about 50 years of age, 
who was affected with a tumor in the vagina, resembling cystic 
tumor. It was first noticed several years before, after straining 
while lifting ; recently it had caused inconvenience by its weight 
and the pain felt during micturition, which was frequent and 
difficult. I perceived, on examination, a large tumor, situated 
in front of the os uteri, which retracted on pressure, was 
flabby, and projected between the labia. Half an inch below 
the urethra was an ulceration, through which a catheter was 
passed into the cavity of the tumor, which proved to be the 
bladder. A sound could only be introduced through the ure- 
thra into the bladder when the latter was reduced to the normal 
position, not when prolapsed. Evidently, the obstruction to 
the passage of the urine through the urethra was the cause of 
the formation of a fistula. She was advised to wear a ring 
pessary, to keep the bladder in position. 

Case CLX. — Uncommon Tumor of the jMons Vene- 
ris. Kemoyal. Cure. — A lady, 42 years of age, noticed, 
soon after confinement, a tumor in the left groin. It gradu- 
ally made its way into the labium of that side ; and, as it en- 
larged, involved the mons veneris, dragging it down, together 
with the integuments of the abdomen, and finally formed a 
large pendulous tumor, hanging between the limbs, covering 
the external organs of generation, and causing much pain and 
inconvenience. 

It was removed, and found to be fibro-cellular, of very firm 
consistence ; the cellular tissue surrounding it, and entering into 
its composition, being infiltrated with serum. Its weight was 
two pounds and two ounces. 

I learned, subsequently, that she was well, and had been safe- 
ly delivered of a healthy child. 



270 FEMALE GENITO-UEINAEY OEGANS. 



VASCULAR AND SENSITIVE TUMOR OF THE FEMALE 
URETHRA. 

A vascular tumor is not infrequently met with, just at the 
entrance to the urethra, in the female, having around its base, 
usually, a bright erythematous blush. It is composed of en- 
larged veins, and is classed by Paget among erectile growths. 
Mr. Hutchinson compares it to hemorrhoids. It is generally 
very sensitive, and is the source of great irritation, causing 
pain, itching, and smarting during micturition, often aggra- 
vated at night : occasionally it is the seat of hemorrhage. 

Extirpation is the only remedy ; and care must be taken 
to excise the whole morbid growth, and even then it is liable to 
recur. A valuable monograph has been written on this subject 
by Dr. Alexander E. Hosack of New York. 

The following cases are illustrative of this affection : — 

Case CLXI. — Sensitive Tumor of the Female Urethra, 
Excision, — The patient was a married woman, 64 years of 
age, never pregnant. She had had good health during early 
life, with the exception of dysmenorrhoea. Her catamenia 
ceased suddenly, when she was fifty-six years old ; and four 
years subsequently she suffered from dysuria, attended with 
severe scalding : at night there was stinging pain in the region 
of the urethra, and pruritus during the day. The external 
genital organs, especially in the vicinity of the urethra, were 
excessively tender. These symptoms increased in severity up to 
June, 1863, when I first saw her. 

I found a vascular excrescence, about the size of a pea, pro- 
truding from the urethra. On the 1st of July, the tumor was 
excised, with a circular portion of the mucous membrane around 
the orifice of the urethra, and the wound cauterized with ni- 
trate of silver. A flexible catheter was then introduced into the 
bladder, and allowed to remain. She soon recovered, and was 
discharged well. The tumor, however, recurred some months 
after the operation, but gave much less trouble. It was re- 
moved as before, and I have not since heard that it returned. 



TUMOR OF THE FEMALE UEETIIRA. 271 

Case CLXII. — Sensitive Tumor of Female Urethra. 
Excision. Complete Relief. —A young woman, 26 years 
old, of dark hair and complexion, had for four years been 
troubled in micturition. The affection, however, had not 
assumed a very severe form until a month before her first 
visit to me. Every passage of water, at this time, was 
attended bv a burnino;, stinoins^ sensation, which was almost 
insupportabk, and finally became so severe as to affect her 
health. AYith the usual delicacy which women feel in com- 
plaints of this nature, she had avoided consulting her physi- 
cian ; and it was only by the advice of her sister, who had been 
a nurse, that she was finally persuaded to apply to me. At 
this time, the mere contact of the clothes was insupportable, 
and she had had one or two attacks of rather profuse bleeding 
from the neighborhood of the urethra. On examination, a 
vascular tumor was found, of the size of a very small pea, 
projecting from the urethra, the mucous membrane at its 
base being highly injected. The tumor, and the surrounding- 
parts, were exquisitely painful to the touch. The patient being 
fully etherized, the tumor was seized with forceps, dragged out, 
and as large a portion as possible of the mucous membrane 
excised. The operation was followed by complete relief; being 
the first case that I have met with where a cure has resulted 
from a single operation ; most of the cases having been attacked 
by caustics or the knife before coming under my observation. 

Case CLXIII. — Sensitive Tumor of Female Urethra. 
Excision. Relief Recurrence of Tumor at the End of Ten 
Years. Excision. Relief. — A lady, 38 years of age, had 
been troubled for nine years with great dysuria, and excessive 
sensitiveness of the parts in the neighborhood of the urethra, so 
that she could not bear even the contact of her clothes i Before 
consulting me, cauterization had been employed ; without giving 
her any relief, however. 

I found a small vascular tumor projecting from the orifice of 
the urethra, bleeding on the slightest touch, and so painful as 
to elicit loud outcries from the patient on the most delicate 
examination. She was etherized, and the mucous membrane of 



272 FEMALE GENITO-URINAKY ORGANS. 

the urethra everted to as great an extent as possible with the 
forceps, and excised. The hemorrhage during the operation 
was quite profuse. 

Relief followed for nearly ten years, when the tumor re- 
appeared, but with less violent symptoms than before. It was 
treated in the same manner as at first, and with as good result. 

I have not heard of its recurrence. 



CANCER or VULYA. 

I have been much struck with the great relief afforded to 
patients with extensive and painful cancerous affections of the 
vulva by a surgical operation. Females are very apt to con- 
ceal the disease until its ravages have made great progress, 
when, from the amount of discharge, the difficulty of locomo- 
tion, and often a painful secondary tumor, they are obliged to 
make it known. In a number of cases, I have removed a can- 
cer occupying the entire labium, extending up into the floor of 
the vagina, and penetrating the urethra above. The wound 
healed rapidly after the operation ; and the patients, so far as I 
know, have done well. The cancer is without doubt epithelial, 
and in my opinion amenable to operation. In the instances in 
w^hich I have practised removal, there has been no recurrence of 
the disease, although some of them were of the most formidable 
character. 

In the case of an old lady, who was suffering excessively 
from a very extensive cancer of the labia and a large secondary 
tumor of the groin, — in whom locomotion was entirely pre- 
vented, and the discharge so acrid as to excoriate the surrounding 
parts over which in addition the urine passed, — I performed 
an operation, removing the whole diseased portion of the pu- 
denda; and the patient recovered the use of her limbs. The 
tumor of the groin was not interfered with. 

Case CLXIV. — Cancer of Vulva. Operation. Re- 
covery. — An unmarried woman, 36 years old, entered the 
Hospital in March, 1865, for an ulcerated cancer, occupying 
the whole extent of the left external labium, also the upper por- 



TUMOR OF VAGINA. 273 

tion of right labium, implicating the vulva, and extending quite 
deeply beneath the surface. It began, a year before, by a hard 
nodulated swelling on the left labium, causing, at first, no in- 
convenience. January, 1865, it discharged freely, and also 
was quite painful. Soon after this, hard globular swellings ap- 
peared in the left groin. On the 30th of March, an operation 
was performed, to remove the entire disease of labia and vulva. 
It was thought useless to attempt to remove the glands in the 
groin, the induration at their bases being very indefinite. When 
the erectile tissue was cut into, the liemorrhage was pretty free, 
and many large vessels required to be tied, — which is generally 
the case in this operation. A few days afterwards, an erysipe- 
latous inflammation occurred in the tumors in the groin, re- 
quiring free incisions. Sloughing took place, terminating in 
the complete destruction of these secondary tumors. The pa- 
tient was discharged well on the 24th of April. 

TUMOR OF VAGINA. 

Case CLXY. — Cystic Tumor of Vagina. Removal. — 
A lady, 26 years of age, well-formed and healthy, two months 
before her confinement perceived a round and elastic tumor in 
the back part of the vagina. At the time of her confinement, 
it was forced down outside the vagina, and subsequently pro- 
truded on any motion, or on her assuming the upright posture. 
When she consulted me afterwards, she was in the fourth 
month of her second pregnancy, and the tumor caused great 
uneasiness. On examination, an elastic tumor the size of 
an orange was found arising from the posterior wall of the 
vagina, and extending from the os uteri to the external organs. 
The finger, being passed into the rectum, could detect the tu- 
mor pressing back and somewhat obstructing the passage of 
the canal. By a little manipulation, it could be gradually 
brought down outside the external organs, and was seen to be 
a rounded, elastic mass, covered with the mucous membrane of 
the vagina. The os uteri was quite large, soft, and patulous, 
and presented the appearance of a much farther advance in 
pregnancy than admitted by the patient. 

35 



274 FEMALE GENITO-UEINARY ORGANS. 

She was etherized ; the tumor was grasped by the hand so 
as to make it tense ; and an incision two inches long made in 
the median line, and a delicate sac exposed. This was now 
partially uncovered, when it gave way, and about a gill of 
cream-colored fluid was evacuated. The sac was completely 
separated from its attachment by the knife and director. The 
wound was left to take care of itself, no stitches being used. 
She had no bad symptoms, and scarcely any sensations to in- 
dicate that an operation had been done. She was kept quiet 
for a week, from fear of the possibility of a miscarriage, and to 
prevent the mucous membrane of the vagina from bagging down 
and forming an inconvenient excrescence. The recovery was 
complete, and did not interfere with her pregnancy, which went 
on to a safe termination. 

POLYPUS UTERI. 

Case CLXVI. — Polypus of Uterus. Hemoval hy Liga- 
ture, — During 1847, a lady fell, while entering her house in 
the evening, and received a severe blow on the lower part of the 
abdomen from the stone step. She was carried into the house 
suiFering greatly, and a profuse uterine hemorrhage followed. 
For some months she was confined to her bed, scarcely able to 
turn from pain, and suffering from occasional returns of the 
bleeding. Coming under the care of an experienced practi- 
tioner, a vaginal examination was made, wliich disclosed the 
existence of a polypoid tumor extruded from the os uteri. 
Being called in consultation, I advised an operation. At this 
period she was suffering from anasmia, and so exhausted as to 
make it unsafe for her to assume the upright position, as the 
attempt was always attended by fainting. A ligature was 
applied to the polypus, and the tumor separated on the fourth 
or fifth day, the subsequent recovery being rapid. 

The patient remained well until 1851, when the recurrence 
of hemorrhage at the menstrual periods, severe pains and bear- 
ing-down sensations in the back and loins, indicated the existence 
of uterine disease. Added to the above symptoms was the 
discharge of a gill of watery fluid from the vagina once in five 
or six days. 



POLYPUS UTERI. 275 

A tumor was discovered occupying the whole fundus of the 
uterus, and projecting into the vagina. With some diffi- 
culty, the finger could be passed into the cavity of the uterus 
through the os, which tightly embraced the central part of the 
polypus ; with the speculum it could be distinctly seen, its 
parietes presenting a white, glistening appearance. A strong 
ligature, made of whip-cord, was applied to its base in the 
following manner : Two porte-noeuds, threaded with the liga- 
ture, were carried up through the os uteri to the base of the 
tumor; then, by taking one in each hand, they were made 
to describe a semicircle around the polypus. The ends of 
the ligature were now engaged in the serre-noeud of Graefe, 
which being carried up to the root of the polypus, the threads 
were disengaged from the porte-noeud, and the ends drawn as 
tight as possible and secured. By means of a screw, the pres- 
sure was increased daily and the tumor destroyed, so that the 
instrument separated at the end of a week, no constitutional 
symptoms of consequence having occurred. 

This patient has since menstruated, and enjoys good health. 

Case CLXYII. — Polypus of Uterus. Removal. — A 
woman, 40 years of age, who had borne a number of chil- 
dren, entered the Hospital in May, 1860, for menorrhagia. 
She attributed it to hard work, and for a year had constantly 
bled more or less daily. A vascular polypus was found pro- 
jecting from the os uteri : it was fiat, and about the size of a 
cherry. The patient said the tumor would occasionally fill up to 
a large size, so as to project through the external organs. The 
os uteri was much enlarged and very hard ; and the body of the 
uterus was tipped back, and could be felt of the size of a large 
orange in the rectuai. I twisted off the polypus with a forceps, 
but could o^et no instrument into the os. The bleedino^ at once 
ceased. Ergot in the form of troches, at the rate of fifteen 
grains three times a day, was then given, and on the second day 
brought on expulsive pains ; but no tumor appeared. At the 
end of a week, the os uteri had diminished to half its previous 
size ; and, a fortnight after the operation, there had been no fur- 
ther hemorrhage, although she constantly had the sensation of its 



276 FEMALE GENITO-URINARY ORGANS. 

returning. The only reason to which I can ascribe the large 
size of the uterus is the constant irritation of the bleeding poly- 
pus and the efflux of blood for its supply. 

Case CLXVIII. — Polypus of Uterus. Removal. — A 
healthy, unmarried woman, 30 years old, of regular menstrua- 
tion, while making some effort was seized with a pain in the 
back and a sensation of something giving way in the pelvis. 
Shortly afterwards, she had hemorrhages, — probably uterine ; 
and, in a few days, noticed a substance projecting between the 
labia. At every subsequent menstrual period she was subject 
to menorrhagia, and recently the bleeding recurred in the inter- 
vals. Her strength was much reduced, and she suffered con- 
stantly from pain in the loins. There was also a leucorrhoeal 
discharge. 

On examination under ether, a red, granulated body, the size 
of a pigeon's Qgg-, was discovered protruding between the labia. 
On passing the finger up the vagina, the tumor was found to be 
attached by a long neck to the inside of the uterus. The os 
was open and everted, so that the finger passed readily into the 
cavity of the womb. 

The tumor was grasped with a pair of broad forceps (such 
as are used for drawing out the tongue), and twisted around 
five or six times, when it came away without resistance. I pre- 
ferred this method to the more tedious one of ligature. There 
was no bleeding, and the following day she was quite well. 



FOREIGN BODY IN VAGINA. 

Case CLXIX. — Large Hair-'pin extracted from the Va- 
gina of a Child thirteen years old. — I was requested by a 
physician to see a child whom he had visited in the morning, 
in whose vagina he had discovered a hair-pin firmly impacted. 
For a number of years, she had been troubled with a purulent 
discharge and other symptoms, for which many physicians had 
been consulted, and many applications had been made without 
avail. As her symptoms were becoming more urgent, her phy- 
sician was consulted, who advised an examination. The girl, 



FOREIGX BODY IN VAGINA. 277 

finding that this was to take place, confessed to her mother, 
that, seven years before, while in company with other children, 
she had introduced something into the vagina, and that she had 
always been aware that its presence was the cause of her 
troubles, and had determined never to disclose the fact, and 
was now induced to do so only by the fear of the threatened 
examination. One prong of a hair-pin was detected just within 
the vagina, which could be drawn down a short distance, expos- 
ing the end of it externally ; but the other end, being firmly 
impacted in the side of the passage, prevented farther movement. 
In the afternoon, I was requested to see the case. The patient 
was a large, healthy-looking girl, thirteen years old, of rather 
more intellect than is usual for one of her age. She was ether- 
ized, as the parts were swollen, and too sore to admit of an 
exploration without giving great pain. On passing the finger 
into the vagina, the Avhole passage was found thickened and of 
almost a callous hardness. The upper part, or bend, of the 
hair-pin was in contact with the cul-de-sac of the vagina. 
Half of one prong was deeply implanted in the wall of the 
vagina to the extent of about two-thirds of its length. It 
was incrusted, to a thickness equal to about a third of its di- 
ameter, with calcareous matter. By careful manipulation, the 
iron was gradually bent to an angle at the point where it pene- 
trated the parietes of the vagina. Two-thirds of it could now 
be drawn outside the passage. Before proceeding farther, the 
finger was passed into the rectum to ascertain if the pin could 
be felt on that side ; but it seemed to have passed more tow- 
ards the tuberosity of the ischium. By exerting considerable 
force, and twisting it in various directions, it was loosened and 
drawn out. Before bending it, an attempt was made to push 
it up into the vagina ; but the passage had become too narrow, 
from the effects of the inflammation, to admit of this manoeuvre. 
She soon entirely recovered. 



278 FEMALE GENITO-UEINARY ORGANS. 



OCCLUSIOJi^ OF THE YAGINA. 

At the time when the first of the following cases came under 
my care, little had been published in regard to occlusion of the 
vagina, and some embarrassment was felt as to the proper 
course to be adopted. Latterly, however, more attention has 
been paid to the subject. 

The subjoined cases give some details in regard to the diag- 
nosis in retention of the menstrual secretion, and the mode of 
giving exit to it, when the anatomical relations of the parts are 
abnormal either from disease, congenital malformation, or diffi- 
cult parturition, and may be of use in future cases of a similar 
character : — 

Case CLXX. — Occlusion of Vagina following a Te- 
dioiis Labor, Yesico-vaginal Fistula. Retention of Cata- 
menia. O'peixition. Hecovery. — 1850. A married woman, 
20 years of age, a year before had been delivered, by means 
of instruments, of a dead child, after a labor of four days. Very 
severe inflammation followed, attended with slouo^hino; of a 
portion of the vesico-vaginal septum, so that the remains of the 
bladder, falling down, became adherent to the posterior wall of 
the vagina, and obliterated the passage. There was also a val- 
vular opening from the neck of the bladder into the lower part 
of the vagina. 

The menstrual secretion had been retained since her confine- 
ment. At first she suffered at the regular periodical returns of 
the catamenia from pain and distention of the abdomen, with a 
sense of bearing down in the rectum. Afterwards, the pain 
became almost constant, and so acute as only to be relieved by 
large doses of narcotics. From these causes she was almost 
bedridden, and very much emaciated. 

The constant dribbling of urine had rendered the orifice of 
the vagina so extremely sensitive that it was impracticable to 
make any examination until the patient had been placed under 
the influence of ether. The cul-de-sac at the commencement 
of the vagina was just sufficient to admit the end of the fore- 



OCCLUSION OF VAGINA. 279 

finger. From its upper part, the urine escaped through the 
valvular opening, so situated that a probe could not be made to 
enter the bladder. On passing the forefinger into the rectum, 
& hard and slightly elastic tumor could be felt about two inches 
from the external orifice, pressing backwards and partially 
obstructing the bowel. The other hand, placed on the abdo- 
men, distinguished a large globular mass rising above the brim 
of the pelvis, pressure on which communicated a distinct 
impulse to the finger in the rectum. 

The above examination led to the conclusion, that the tumor 
felt in the abdomen and rectum was the uterus and upper part 
of the vagina distended by the menstrual fluid. 

The patient, being fully etherized, was placed on the edge of 
the bed, with the limbs supported as in the operation for lith- 
otomy, and the labia held apart by silver hooks. The fore- 
finger was now placed in the rectum to serve as a guide, and a 
transverse incision made across the lower part of the vagina 
through its parietes, so as to expose the cellular membrane 
lying between it and the rectum. This dissection, passing 
under that portion of the vagina which served as a fundus to 
the bladder, was continued upwards between these organs for 
two or three inches, until the distended sac could be distinctly 
felt. 

A very large trocar and canuia was now plunged into the 
tumor; and, when withdrawn, a quantity of thick, tarry-looking 
fluid began very slowly to flow through the tube. About a pint 
was allowed to escape, when the canuia was withdrawn, being 
too short to be left with safety, and a female catheter introduced 
in its place. 

In the afternoon of the day of the operation, she was com- 
fortable. At intervals, however, there were severe contractile 
pains in the uterus like those attending the first stages of partu- 
rition ; and by them the catamenial fluid was forcibly expelled. 
Warm fomentations were applied to the back, and an opiate 
administered, by which her sufferings were temporarily relieved. 

On the following day, I learned that she had passed an uneasy 
night; the pains continuing at intervals, causing a free evacua- 
tion of fluid. Her mother estimated, that at least two quarts 



280 FEMALE GENITO-URINARY ORGANS. 

had passed through the instrument, with the effect of greatly 
diminishing the tension of the abdomen. Towards evening, she 
had an access of pain and fever, with some obstruction to the 
discharge : the bowels being constipated, she was ordered castor 
oil. The medicine operated with much relief. The uterus 
resumed its action, and could be felt above the pubes, some- 
what tender on pressure, and contracted into a small, well- 
defined tumor. 

For about a week she improved steadily, the discharge con- 
tinuing at intervals. It w^as with the utmost difficulty that any 
instrument could be retained in the opening ; and, when dis- 
placed, the aperture was found to have so contracted as to 
render its replacement almost impracticable. The external 
organs were very sensitive. 

During the second week, she was attacked with a catarrhal 
affection, during which, from some exposure or error in diet, 
she was suddenly seized with violent pains in the abdomen, 
meteorism, great sensibility on pressure, with other symptoms 
denoting peritoneal inflammation. These were gradually re- 
lieved by treatment, the patient barely escaping with her life. 
During this attack, the canula had necessarily been removed, and 
every measure for maintaining the opening abandoned. The 
menstrual secretion came on naturally, about four weeks after 
the operation, and found an exit without difficulty. 

The subsequent improvement was gradual, and only inter- 
rupted in the course of the summer by an attack of varioloid. 

I subsequently heard from this lady through her mother, who 
informed me that from a mere skeleton her daughter had 
become quite robust ; that she had regained her health and 
strength so as to be able to use exercise on horseback ; and that 
the menstrual secretion was natural at the regular periods. 

Case CLXXI. — Occlusion of Yagina after Lahor. Re- 
tention of Catamenia. Operation. Relief, — On Feb. 4, 
1850, I was applied to by a married woman, aged 30, In 
consequence of the suffering produced by the retention of the 
menstrual fluid from an occlusion of the vagina subsequent to 
parturition. 



OCCLUSION OF VAGINA. 281 

In the August previous, she had been delivered of her first 
child after a labor of four days, during a portion of which time 
the head of the infant remained in the pelvis. Instruments 
were used, but ineffectually ; and the delivery was ultimately 
accomplished without them. Very severe inflammatory symp- 
toms, attended with a purulent discharge, followed ; and finally 
it was discovered that the vagina had become entirely obliter- 
ated. From that time, the return of every catamenial period 
had been marked by the most distressing pains in the back 
and abdomen, lasting three or four days, and progressively 
increasing in violence, accompanied with some constitutional 
disturbance. These repeated attacks gradually impaired her 
health. 

An examination showed that the vagina was entirely closed, 
and hardly a perceptible cicatrix could be detected to indicate 
the line of union. At the lower part of the vulva, an orifice 
was discovered large enough to admit a probe, which, on being 
introduced, could be passed up a distance of three inches in the 
direction of the uterus, and was distinctly perceived through 
the recto-vaginal parietes by the finger introduced into the 
rectum. At this period, no abdominal or rectal tumor was 
ascertained to exist. It was determined to etherize her, and 
attempt to restore the vaginal passage. 

The patient being fully etherized, a bougie was passed into 
the fistulous opening. This was followed by the finger ; and, 
by proceeding carefully in this way, distending and separat- 
ing the adherent parts, a free opening was made of about three 
inches and a half or four inches. At this point, a regular orga- 
nized septum precluded any advance, unless by the assistance of 
cutting instruments. A bit of sponge was therefore introduced, 
and directed to be kept in situ during the night. 

On the day following, the sponge was removed, and replaced 
by another. This course was continued for a week, when, no 
tumor being discovered in the rectum to indicate the situation 
of the distended uterus, and there being no trace of the os 
uteri in the vagina, it was determined to suspend any farther 
proceedings, enjoining upon her to use all necessary means 
for keeping the passage open until the distention caused by the 

36 



282 FEMALE GENITO-UKINARY ORGANS. 

menstrual secretion should be sufficient to serve as a guide to 
the knife. 

Two months after, having rigorously followed up the above 
directions, she visited me a second time ; suffering in the same 
way as before, and urgently demanding relief. An examina- 
tion elicited no change in the situation of the parts. As the 
pain was very distressing, however, I consented to make an 
incision at the upper part of the vagina, with the hope of throw- 
ing some light upon the direction in which the enlargement of 
the uterus was taking place. This was done, and the dissection 
carried as far as was thought safe, but with no good result. 

On the 3d of May, I again saw her. She had for four days 
been in extreme pain. The vagina, so for as it had been 
dilated, I found to be of its natural dimensions. The finofer, 
introduced into the rectum, at once detected, about two inches 
from the anus, a hard tumor, such as might be presented by the 
enlarged prostate in the male, and with as little sensation of fluc- 
tuation. She informed me, that, for the previous twenty-four 
hours, there had been a bloody discharge from the vagina ; and 
traces of this secretion were perceived when that passage was 
examined, apj^arently coming from the mucous membrane. Not 
the slightest indication of any tumor could be found in this 
direction, even when the abdomen was strongly pressed upon. 

Although the rectal tumor was free from fluctuation, I had 
no question, from my previous experience, but that it proceeded 
from an enlargement by distention with fluid of the upper part 
of the vagina or uterus, and therefore proposed an operation, 
which was readily acceded to. 

On the 3d of July, the operation was performed, the patient 
being first etherized. The upper and back part of the vagina 
was cut freely through with a round-bladed bistoury ; and very 
soon, with a slight dissection, the tumor which had been felt by 
the rectum presented itself, but much softer and more elastic 
than when examined through the intestinal wall. A large 
trocar was now plunged into it in a direction obliquely back- 
ward, in order to avoid wounding the os uteri, in case that 
organ projected into the vagina. A free discharge of the black, 
tarry substance described in the last case at once took place. 



OCCLUSION OF VAGINA. 283 

About half a pint of fluid having escaped, the canula was 
withdrawn, and the finger introduced into the opening, which 
was enlarged in either direction with a probe-pointed bistoury. 

On exploring the cavity, no distinct projection answering to 
the OS uteri could be discovered. The whole interior, both 
of the uterus and vagina, seemed to form but a single receptacle, 
a little contracted at one point, like the hour-glass contraction 
of the uterus, this apparently answering to the situation of 
the OS tincaj. The mucous membrane appeared much swollen, 
and traversed by large vessels, which stood out in bold relief. 
A long, narrow bit of sponge was passed into the vagina, half 
of it being allowed to remain within and half without the open- 
ing just made. The patient declared herself at once relieved 
from all her distressing symptoms. 

From* the difficulty of maintaining the new opening, it was 
found necessary, a few days after the operation, to introduce a 
sponge tent, which was removed daily, and gradually increased 
in size. At the end of a week, the patient, having exposed her- 
self immediately after the sponge had been removed, was seized 
with severe pains in the abdomen and in the lower part of the 
back, tympanites, and all the symptoms denoting inflammation. 
The treatment consisted in the application of leeches, and the 
other measures usually adopted. In three or four days, the pain 
and tenderness gradually concentrated at the lower and left side 
of the abdomen, where a large, hard tumor could be perceived 
through the parietes. These symptoms were suddenly relieved 
by the discharge of a quantity of pus from the vagina. The 
tumor in the abdomen now gradually subsided. The intestinal 
canal remained for a length of time quite irritable, diarrhoea 
being produced whenever she took solid food. 

She left town on July 31st, quite weak, but improving. 

She was advised to have a small rectal bougie passed into the 
opening in the vagina daily, as the disposition to contraction 
was still great ; and it was thought unsafe, through fear of 
exciting a fresh attack of inflammation, to maintain any sub- 
stance constantly in the aperture. For quite a number of 
years after the operation, she required to be kept under treat- 
ment, at times, to prevent the recurrence of the occlusion ; but, 
in the intervals, enjoyed very fair health. 



284 FEMALE GENITO-URINARY ORGANS. 

Case CLXXII. — Congenital Occlusion of Yagina. Op- 
eration. JRecovery. — 1851. A girl, aged 17 years, had been 
suffering for two years with a sense of distention and weight 
in the lower part of the abdomen and back, attended by a 
forcible pressure in the vagina, as if for the purpose of expelling 
some foreign substance. She had also been greatly annoyed 
with a frequent desire to micturate, and passed water as 
often as every twenty minutes through the day, but less fre- 
quently at night. She suftered much severe pain at the 
extremity of the urethra, which was aggravated by the passage 
of the water. She had never menstruated. 

The following ajDpearances were found : On separating the 
external labia, no traces of the vagina were visible. At the 
central part of the fossa, usually occupied by this outlet, the 
meatus urinarius was perceived surrounded by small vegeta- 
tions, which, on the slightest touch, elicited the most violent 
resistance and cries from the patient. A probe being passed 
into the urethra, its farther progress was resisted at the distance 
of an inch from the orifice ; but finally, by turning it upwards 
in almost a vertical direction, it entered the bladder, which 
was very much contracted. 

The finger was introduced into the rectum, and at once 
detected a hard tumor two inches from the anus, pressing back- 
wards against the spine. It seemed quite solid, and without 
the slightest indications of elasticity. On passing the hand 
over the abdomen at its lower part, a hard projection was felt 
in the centre just above the pubis, having a prolongation about 
four inches in length, extending into the right iliac region. 
Pressure on this swelling caused a movement of the tumor in 
the rectum, and was attended with much suiFering. 

No doubt remained in my mind that these tumors were 
caused by a retention of the menstrual fluid in the uterus, upper 
part of the vagina, and the Fallopian tubes. 

The patient being fully etherized with chloric ether, an inci- 
sion was made transversely across the mucous membrane of the 
lower part of the vagina. This disclosed muscular fibres, which 
being carefully divided through the aperture thus made, a deli- 
cate membrane of a dark color protruded. It was suggested 



OCCLUSION OF VAGINA. 285 

by one of the gentlemen present, that this might possibly be the 
peritoneum, which, in a case of malformation and non-existence 
of the vagina, had taken an abnormal direction. For the pm-- 
pose of testing this, I attempted to separate it from the sm-- 
rounding textures, knowing the loose character of the cellular 
tissue which attaches the peritoneum to the neighboring organs 
and the pelvis. This was at once found to be impracticable; 
and, on a renewal of the effort, the resisting part yielded, and 
the finger passed through into Avhat appeared at first to be the 
abdominal cavity, so well defined was the anatomy of the walls 
of the pelvis. The absence of intestines, and the appearance 
of a small quantity of dark-colored fluid by the side of the 
finger, soon made it evident that the vagina had been opened. 
The size of the cavity occupying the entire pelvis, and the com- 
plete absence of os uteri or other boundary between the uterus 
and vagina, were on examination sufficiently evident to all pres- 
ent. 

By the aid of slight pressure on the abdomen, about half a 
pint of thick, tenacious fluid escaped. As the uterus did not at 
once take on contractions, no further efforts were made to evacu- 
ate the fluid ; but a bit of sponge was introduced into the open- 
ing to prevent the parietes from adhering. The vegetations at 
the orifice of the urethra were now removed by the scissors, and 
the base of the tumors cauterized with nitrate of silver. To 
show the extreme sensibility of these tumors, it may be ob- 
served, that, as soon as they were interfered with, the patient, 
although well etherized and perfectly passive through all the 
previous operation, immediately drew back as if in extreme 
pain. 

On the day following the operation, she was reported to have 
passed a good night. The sponge was removed from the vagi- 
na, and a free discharge of the peculiar fluid took place ; after a 
few hours, it w^as again introduced. No urine had been passed 
since the operation : during the succeeding night, however, a 
copious evacuation of the bladder took place. She continued to 
improve, and the tumor of the abdomen to diminish. The fin- 
ger, passed into the vagina, could distinguish the os uteri, as it 
were, gradually forming itself. It was about the size of a 



286 FEMALE GENITO-URINARY OEGANS. 

tumbler, with thick edges, and covered with dilated blood- 
vessels. The sponge tent, when withdrawn, was very offen- 
sive. 

A week after the operation, she was quite well ; the urine 
was passed naturally and without pain, the sensitive tumors of 
the urethra having been destroyed ; the discharge from the 
vagina had partially ceased, or had been replaced by a serous 
exudation ; and her appetite and digestion were natural. 

At her urgent request, she was then allowed to return home 
to the country, where the treatment was continued by her phy- 
sician. A month after the operation, the vaginal discharge 
ceased, and she was reported to me as well. 

Case CLXXIII. — Congenital Occlusion of the Vagina. 
Operation. Relief. — A girl, 14 years old, began to suffer, 
two years before I saw her, with pains in the lower part of the 
back and abdomen. These pains gradually assumed a periodi- 
cal character, coming on at an interval of four weeks, and were 
so intense as to require alleviation by means of medicine. 

A physician, being consulted, suspected an obstruction of the 
vagina ; and an examination confirmed his suspicions, showing 
this passage to be completely occluded. An incision was made 
through the solid obstruction which presented at that part, with 
the hopes of discovering a cavity containing the menstrual fluid ; 
but the operation met with no success. From this time, the 
sufferings of the patient gradually increased, and, at the men- 
strual periods, were so severe as to produce a degree of prostra- 
tion which confined her for some days to her bed, and finally 
even threatened life. 

When I first saw her, the external organs of generation were 
so sensitive as to cause great complaint on any attempt at an 
examination. The external labia were found to be well devel- 
oped. The orifice of the urethra occupied its normal position, 
or was a little lower than natural. Below this, not the slightest 
depression indicated the orifice of the vagina. The finger, being 
introduced into the rectum, detected, at the distance of about 
two inches from the anus, a hard, globular tumor, the size of a 
billiard-ball. Before removino^ the finger from the rectum, 



OCCLUSION OF VAGINA. 287 

a catheter was passed into the bladder : and this was at once felt 
by the finger in the rectum, in the median line ; the coats of 
the bladder and rectum only intervening, for a distance of one 
or two inches, that is, as far as the above-mentioned tumor. 
At this point, the catheter could be made to pass on each side 
of the tumor, but was with difficulty detected in the rectum. I 
had no doubt, from the result of the examination, that the 
tumor felt in the rectum was the upper part of the vagina and 
uterus distended by fluid, and the cause of the serious symptoms 
under which the patient labored. An operation was therefore 
proposed, and at once, with the assistance of her physician, 
performed. Ana3sthesia being induced, a transverse incision 
was made directly below the orifice of the urethra. With much 
caution, a dissection was now made between the rectum and the 
bladder, until, by cutting and separating the tissues with the 
fingers, the tumor described as felt in the rectum was reached, 
lying very deep, and affording but little opportunity for a fair 
examination. The depth at which it lay, and its apparent 
solidity, for a moment caused some embarrassment as to the 
proper course to be pursued, especially as one of the gentlemen 
present seemed convinced, from its hardness, that it could not 
contain a fluid. But, finally, being satisfied in my own mind 
that the tumor could be nothing else but what had been sus- 
pected, I determined on puncturing it. The escape of the thick, 
tarry fluid at once confirmed the truth of the diagnosis. The 
aperture was now enlarged so as to allow two fingers to pass 
freely up into the cavity containing the fluid, which was appar- 
ently the uterus and upper part of the vagina distended so as to 
form a single sac. 

The patient, on recovering from the effects of etherization, 
declared herself entirely relieved from her previous state of suf- 
fering. The use of the prepared sponge, to prevent the closure 
of the passage, was advised ; as also the occasional introduction 
of bougies, to maintain, if possible, the normal size of the 
canal. The operation was followed by complete recovery. 

Case CLXXIY. — Occlusion of the Vagina occurring 
soon after Marriage. Operation, Relief — The patient 



288 FEMALE GENITO-UKINARY OEGANS. 

was a widow, 45 years of age. The account she gave was, 
that she was married at an earlj age ; that les 'premieres ap- 
proches du miari were so violent as to cause a severe inflam- 
mation of the vagina, which eventually termina>ted in the almost 
complete closure of the upper part of the canal. At the cata- 
menial periods, much difficulty and suffering were experienced 
in the egress of menstrual fluid, which was discharged slowly, 
and apparently by a circuitous route. She suffered from this 
cause until within three years, when that function ceased to be 
performed, but was replaced by a mucous secretion. Her health 
was poor, and she had been more or less troubled with pains in 
the back and loins, all of which she attributed to the retention 
of fluids in the uterus. 

An obstruction was detected about two inches from the ori- 
fice of the vagina, caused apparently by an adhesion of its 
parietes. With the aid of the speculum, a small aperture was 
observed on one side, into which a probe penetrated a short 
distance. 

As the patient insisted on having an operation, I consented to 
do it; although, at the same time, I informed her that it was 
very doubtful whether the obstruction was the cause of the 
symptoms, considering the present state of the functions of the 
uterus. 

A director was forced into the passage, which had at first only 
admitted a probe. This was followed by a larger instrument ; 
and, by proceeding gradually, it was shortly found possible to 
use the dressing forceps. By this means, the passage was finally 
enlarged so as to admit the little finger, when, by tearing and 
distending the parts, almost the full size of the original passage 
was restored, and the extremity of the os uteri exposed, buried 
in the adjacent structures. 

The calibre of the canal was maintained by the same means 
as had been resorted to in the preceding cases. The patient ex- 
pressed herself much relieved by the operation ; and, when seen 
a month afterwards, there had been no recurrence of the previ- 
ous symptoms under which she had suffered. 



OCCLUSION OF VAGINA. 289 

Case CLXXV. — Occlusion of the Vagina. Retention 
of the Menstrual Fluid. Operation, Relief. — A girl, 
16 years old, was first taken, in 1855, with pains in the back 
and loins, such as precede the menstrual flux, which did not, 
however, appear. The pains were repeated every month, 
usually lasting three or four days. In January, 1857, she 
suffered from retention of urine, which was relieved by the 
use of the catheter. The same thing occurred in February and 
March. In April, while passing the catheter, it was found to 
encounter a resisting substance ; and, in order to get it into the 
bladder, it was necessary greatly to depress the handle and ele- 
vate the point, to surmount the obstacle. Her physician then 
made a further examination, and discovered a round, hard tumor 
in the abdomen, and another projecting into the rectum. 

I saw this patient on the 26th of April, and discovered an 
occlusion of the vagina, and a great collection of the menstrual 
fluid in the uterus. It being inconvenient to treat the patient at 
her own home, it was decided by the friends to send her to the 
Hospital, under my care. 

Previous to the operation, the following were the phenomena 
elicited by an examination : A cul-de-sac about half an inch in 
depth constituted the vagina, at the lower part of which was a 
white line, or puckering, perhaps a cicatrix, the result of some 
previous inflammation. A catheter could not be passed directly 
into the bladder, as it encountered an elastic substance ; and it 
was necessary to elevate the instrument almost perpendicularly 
to introduce it into that cavity. In the rectum, a large, hard, in- 
elastic tumor was to be felt, two inches or more from the anus, 
nearly filling the pelvis. A large tumor could also be distin- 
guished in the abdomen, extending just above the umbilicus ; 
and the patient said that occasionally she could feel two lateral 
tumors there. During April, the pains had been incessant, as 
if for the expulsion of some substance from the body. The 
sister stated, in explanation of the cause of the obliteration, that 
she had heard the parents say, that for a long time, when the 
child was two or three years old, it had been affected by an ulcer 
in that region. 

The patient being etherized, and the bladder emptied, a free 

37 



290 FEMALE GENITO-URINARY ORGANS. 

transverse incision was made across the cul-de-sac; and, with a 
little dissection, a delicate bladder-like substance was brought 
into view. Pressure being now made on the abdomen, and the 
pelvic tumor made tense so as to project through the incision, a 
large trocar was plunged into the cavity, and at once a thick, 
tarry fluid began to flow slowly out. The finger was now 
gradually insinuated, a bistoury introduced, and the opening 
enlarged so as to leave no feeling of constriction in any direc- 
tion. The forefinger, being passed freely into the cavity, could 
detect no sac ; but the walls of the pelvis could be felt on all 
sides, the collection of fluid having been so great as to distend 
the uterus to its utmost capacity, and render its walls so thin 
that they could scarcely be distinguished. She was placed in 
bed, and the fluid allowed to escape gradually, which it con- 
tinued to do during the day. About a quart of fluid escaped, 
which at once coagulated, expelling but little serum. Dr. Cal- 
vin Ellis made the following microscopic observations : " The 
menstrual fluid removed from the vagina contained epithelium 
cells ; yellow, granular corpuscles, of various sizes ; blood 
globules, evidently recent ; and very small, translucent globules 
with distinct, though pale, outlines." On the following and 
second days, the os uteri was observed to be slowly forming it- 
self, and the thick walls of the uterus could be detected. 

The patient raj^idly recovered. 

In the first of the cases which have been given, the only 
apparently feasible way of arriving at the distended uterus 
was adopted ; viz., that of penetrating to it by a dissection car- 
ried up between the rectum and vagina. The proceeding even- 
tuated more satisfactorily than could have been expected. The 
greatest obstacle to a rapid recovery was the diflSculty of main- 
taining the new opening, on account of the disposition to con- 
traction ; and this was found to be true in all the cases. What 
appeared to be a large, free opening, with no restriction on any 
side but the bones of the pelvis, in the course of a few days 
was contracted to a firm, unyielding ring, into which it was diffi- 
cult to introduce a small bougie. The sponge tent, when it 
could be borne, at once dilated the aperture again to a size as 
great as could be wished ; but the extreme sensitiveness of the 



OCCLUSION OF OS UTERI. 291 

parts prohibited, in the case under consideration, a resort to 
this powerful agent. In fact, it was finally found necessary, on 
account of the great resistance made by the patient, to desist 
entirely from all applications, and leave the course of it to 
nature. The subsequent month, the catamenia appeared 
slightly ; and there was, so far as I know, no obstruction to it 
afterwards. 

In the second case, the obliteration of the vagina, which was 
closed throughout nearly its whole extent from the upper part 
to the vulva, was also caused by laborious parturition. 

It may serve as an example to show the necessity of making 
inquiries, after a severe case of labor, as to the degree of local 
inflammation, and of taking measures for preventing, if possi- 
ble, such adhesion as occurred in the second instance. This is 
a matter of difficulty and delicacy; but, as so much is at stake, 
these considerations should give way to a correct appreciation of 
the dano-er which would ensue from neo-lectino: an examination, 
when the discharge from the vagina is so offensive as to sug- 
gest the possibility of gangrene and subsequent adhesive inflam- 
mation. 

It may not be useless to call attention to the great resistance, 
and, in two of the cases, entire want of fluctuation, which ex- 
isted in the distended sac formed by the uterus and vagina, as 
felt through the rectum, since this might lead the surgeon to 
doubt the accuracy of his diagnosis, did not other marks assist 
in forming it. 

Recently, I have had two cases of apparently entire oblitera- 
tion of the vagina in married women, in w^iom conception has 
taken place, and at the time of labor the head of the child forced 
its w^ay through the septum without injury to the neighboring 
parts. Both cases have done well, and there has been no return 
of the occlusion. 



OCCLUSION OF OS UTERI. 

Case CLXXVI. — Occlusion of Os Uteri. Collection of 
Pus in Uterus. Opei^ation, Progressing Recovery from 
Uterine Disease. Death from Gastric Disorder. — In the 



292 FEMALE GENITO-UEINARY ORGANS. 

following case, I was called in consultation. A young woman, 
17 years of age, on the second day of her regular menstrual 
period, wet her feet ; the catamenial discharge suddenly ceased, 
and she had a rigor, followed by pain from left ilium to ribs. 
After a little treatment, she was able to be about. The 
menses not appearing six weeks subsequent to their suppression, 
she consulted a physician, who noticed an unusual fulness above 
the pubes. This rapidly increased, and in a few weeks the pa- 
tient presented the appearance of a person at the seventh month 
of utero-gestation. On examination, the uterus gave the sen- 
sation of being distended, and no entrance could be made into 
its cavity with a bougie or sound. 

At the time I was called, the abdomen was slightly sensitive 
to pressure, and projected anteriorly to a great degree ; but there 
was no corresponding lateral fulness, which we usually see in 
pregnancy. 

After a careful examination, I decided to puncture the os, 
and, passing a trocar into it with considerable force, seven pints 
of offensive pus were evacuated. 

For a time the girl improved ; and at a second operation, four 
weeks after the first, three pints of pus were removed. 

About a week after the second operation, the patient, having 
previously lived on a liquid farinaceous diet, ate immoderately 
of potatoes and cabbage. She was immediately seized with 
purging and bilious vomiting, which resisted all remedies, and 
sank rapidly and died. Her physician informed me that no un- 
favorable re-action followed either operation, and that she was 
doing very well up to the time when she committed the above 



excess m eatmg. 



No post-mortem was allowed. 

Case CLXXYII. — Occlusion of the Uterus. Rupture of 
the Left Fallopian Tube, Peritonitis. Death. — 1858. 
The patient w^as a woman 40 years of age, large and fat. 
About the year 1854, she had a very severe confinement, and 
had never menstruated since. For the last nine months, she 
had been for the most part confined to her bed, and suffered 
extreme pain. Dr. B. Brown, on examination of the abdomen, 



OCCLUSION OF OS UTERI. 293 

found a large, firm tumor, which he at once recognized as the 
uterus distended by the retained menstrual fluid. AVhen I saw 
her, in consultation, this tumor was very prominent, standing 
out in bold relief from the abdomen. Its upper part, toward the 
sternum, was flat; below, toward the pelvis, round; and in its 
centre was a deep depression. On examination of the vagina, 
this canal was found to terminate in a smooth cul-de-sac, and 
not the slightest mark of the os uteri could be distinguished, 
nor any thing to mark the point of its obliteration, except 
a very slight roughness on the vesical side of the vagina. 
By the rectum, no tumor could at first be found ; but, by 
pressing the finger very high up into the pelvis, the point of a 
firm, solid mass, of a conical shape, could be reached. The 
patient being in great suffering, it was decided to appoint a 
day for cutting down at the upper part of the cul-de-sac of the 
vagina, and attempting to reach the tumor. On the day before 
the one fixed for the operation, her physician called on me to say 
that it would be unnecessary, as, very shortly after the investi- 
gation had been made, a bloody or tarry discharge from the 
vagina had commenced to flow, and had continued to do so since, 
being accompanied by forcing uterine pains, and with a great 
diminution of the abdominal swelling. Under the circumstances, 
it was thought best to make an examination with the speculum, 
on the following day, in order, if necessary, to take the oppor- 
tunity of enlarging the opening into the uterus. A speculum 
being introduced, at once revealed, at the upper part of the 
vagina, a thin, bladder-like tumor, from which, by a small 
opening, the tarry fluid exuded more freely when pressure was 
made on the abdomen. The speculum being withdrawn, the 
finger at once penetrated the thin partition alluded to, and could 
be carried for some distance, in a curved direction, toward the 
right groin, being prevented from passing toward the abdomen 
by a firm, unyielding tumor, which appeared to be the uterus, 
firmly distended by fluid. A catheter, being passed into the 
bladder, showed that organ to be forced down into the pelvis ; 
and the finger could easily be passed beyond it. It was decided 
to temporize, especially as the discharge continued, and the pa- 
tient was getting ease. In the mean time, it should be stated. 



294 FEMALE GENITO-UEINARY ORGANS. 

the right lobe of the abdominal tumor had disappeared. The 
patient suffered no inconvenience or pain from the examination, 
which was a slight one. 

The following day, she was suddenly seized with a violent 
pain in the abdomen. All the signs of high peritoneal irri- 
tation were evident, and continued for about two days, when 
she died. 

A post-mortem examination explained the cause of death. 
The right lobe of the tumor had been formed by the uterus, 
which had emptied itself through the vagina. The left lobe 
consisted of the left Fallopian tube, enormously distended into 
a very delicate sac, by the retained menstrual fluid. There was 
no communication between the Fallopian tube and the uterus ; 
and the former had ruptured, and discharged its contents into 
the abdominal cavity, causing death. This tumor, which was 
felt through the walls of the vagina and uterus, had been forced 
over into the right groin. The cavity of the uterus was con- 
tinuous with the vagina, the os uteri being obliterated. In one 
or two cases of occlusion of the vagina which I have had, both 
Fallopian tubes, in a distended state, could be felt lying on 
the uterus, but were completely emptied by the operation, .at 
the same time with the uterus. 



HYPERTROPHY OF CERVIX UTERI. 

Case CLXXYIII. — Hypertropic Elongation of the Cer- 
vix Uteri of tiventy-six years' standing, with Frojection of 
the Enlarged Os beyond Extei^nal Organs, Ulceration. 
Hemorrhage, Operation, followed by Complete Cure. — 
1862. The following case fully sustains the anatomical de- 
scription of the disease as given by Huguier in his very inter- 
esting and important work. It also shows how unsafe any 
surgical procedure would be, based on the idea of a simple 
enlargement of the os and cervix uteri, without taking into view 
the very remarkable displacements of other organs which occur 
in the course of the disease when it has proceeded so far as to 
be projected to any extent beyond the labia. 

A lady, 56 years old, and of rather a delicate constitution, 



HYPERTROPHY OF CERVIX UTERI. 295 

married when twenty-nine years of age, shortly after her mar- 
riage took a long voyage, and suffered severely from sea-sick- 
ness, followed by a miscarriage. About a year after, she was 
confined with her first child, having a tedious labor : this was 
followed by some prolapsus of the womb. During a subse- 
quent pregnancy, the prolapsus was relieved ; but, after the 
birth of the child, it was reproduced in a greater degree than 
before, and since then she may be said to have been continually 
suffering from disease of the womb. When I first saw her, 
the OS uteri was enlarged, and projected between the external 
organs, irritating all the neighboring parts, and giving rise to 
constant embarrassment in locomotion. The brain also, to a 
considerable extent, was sympathetically affected ; and for a 
number of years she had been scarcely ever free from a sense 
of weight and pain in the head. For some months before I 
first attended her, she had been confined to her room, both 
from the irritation of the disease, which caused great difficulty 
in walking, and from the debility produced by repeated and 
severe hemorrhages from an ulcer of about the size of a quarter 
of a dollar, situated near the end of the tumor, and similar to 
the ulcerations noticed in such cases by M. Huguier. The tu- 
mor seemed to be of an erectile character, having periods of 
increase and diminution of size, the former state being ac- 
companied by an eft'usion of blood from its face. 

At the time of the operation, she was quite pale and thin, and 
so feeble as scarcely to be able to move about the room. The 
tumor presented the following appearances : It was from three 
to four inches long, and about four inches in circumference at 
its extremity, its base covered by mucous membrane, which, 
from long exposure, had, to a certain extent, assumed the char- 
acter of skin. On the under and back part of the tumor, near 
its end, was the opening of the os, into which the finger could 
be introduced to the extent of from two to three inches. A 
probe passed about two inches farther. At the base of the 
external tumor was the meatus urinarius. A catheter intro- 
duced into the bladder took a downward direction, and its point 
could be felt half-way down the tumor. Of course, there was 
no cul-de-sac of the vagina in front ; but behind the tumor the 



296 FEMALE GENITO-URINARY ORGANS. 

finger could be introduced to a depth of from two to three 
inches. On exploring the rectum by the touch, the finger 
could be hooked downwards into the peritoneal cul-de-sac, 
which was dragged down by the tumor to a distance of about 
two inches external to the cavity of the pelvis. The body of 
the uterus was felt, about the thickness of the thumb, and an 
inch and a half long, in its natural position. It will be seen, 
from the above description, that, by any operation for re- 
moving all the tumor which projected between the labia, about 
a third or a half of the bladder and a considerable portion 
of the peritoneal cul-de-sac would be included in the inci- 
sions. 

The operation was performed on the 18th of November, 1862. 
The patient being etherized, the legs bent as in the operation for 
lithotomy, the extremity of the tumor was firmly seized by 
strong hooked forceps, and drawn downwards and forwards. 
An incision was made in the back part of the tumor, about two 
inches from its extremity, and just in front of the peritoneal 
cul-de-sac, which was marked by the finger hooked down into 
it from the rectum. This investment being dissected backwards, 
the enlarged cervix was cut into about an inch higher up, until 
its cavity was opened. Large vessels, which now spouted in 
every direction, were tied. The dissection was then continued 
in front. The tumor being carried backwards and a catheter 
introduced into the bladder, an incision was made directly in 
front of it, and the bladder dissected ofi* from the body of the 
tumor as far as the level of the incision on the posterior aspect 
of the cervix. The section of the tumor was now completed, 
the base of it being firmly held by the hooked forceps until all the 
bleeding vessels w^ere secured by ligatures. The form of 
the incision is well shown, in the woodcut, by the curved dotted 
lines s, s. Great care was taken to make the dissection slowly, 
and to secure every vessel as soon as cut ; and by this means, 
although many vessels were divided, the loss of blood was very 
moderate. On relaxing the hold with the forceps, the portion 
of the uterus which remained, together with the adjacent organs, 
resumed their natural position in the pelvis. At the end of the 
operation, the pulse, probably from the stimulus of the ether, 



HYPERTROPHY OF CERVIX UTERI. 297 

was much strono-er than at the commencement. There was 
some nausea produced by the ether, but no vomiting. She took 
brandy in the course of the night, and paregoric, for a pain in 
the abdomen. All went on well for two or three days ; on the 
23d, ha^•ing some pain in the abdomen, she Avas relieved by a 
hot fomentation. On the 24th was comfortable ; had an opi- 
ate at night. On the 25th, having gone on perfectly well for 
a week, she was seized with a very severe chill, which lasted 
three-quarters of an hour, and was followed by great re-action, 
hot skin, intense headache, great thirst, &c. I could not dis- 
cover the slightest tenderness of the abdomen or any other evi- 
dence of local trouble, and I was told that she was subject to 
similar attacks. I had thus for been unwillino; to disturb the 
bowels with medicine. An enema was ordered, which had no 
effect, and was followed by a dose of tincture of rhubarb. On 
the following day, the 26th, she was wholly free from fever; 
and, the medicine having not yet operated, a dose of infusion of 
rhubarb was given, with the effect of producing two dejections. 
After this, she began to take solid food. On the 1st of Decem- 
ber, she had another chill, which was relieved as before. An 
examination at this time, with the speculum, showed the surface, 
from which the tumor had been removed, contracted to the size 
of a quarter of a dollar ; two or three ligatures which still ad- 
hered were taken away. About four weeks after the operation, 
the patient was able to walk about, and was completely relieved 
of all irritation about the pelvic organs, wliich Avere retained in 
their natural positions. The pain and feeling of weight in the 
head, which had oppressed her so long, had passed off as if a 
cloud had been swept away. She returned home about the mid- 
dle of December, and I had the satisfaction of seeing her en- 
tirely cured about two months later. During the latter part of 
her stay at the Hospital, she was kept on as full diet as she 
could bear, and porter and spirits Avere given freely, with the 
effect of relieving the very antemic condition under which she 
labored when she entered. 

This case is interesting from the perfect cure of a complicated 
and rare disease of many years' duration, and from the operation 
being the only one, so far as I know, that has been done in 



298 



FEMALE GENITO-UEINARY ORGANS. 



Boston, and, with the exception of Dr. Martin's case, in Rox- 
bury, the only one done in this vicinity. 

I heard from this hidy nearly eleven months after the opera- 
tion, in a condition of almost perfect health. 




A. Mons Veneris. 

B. Right portion of sj'mphysis pubis seyered 

through obturator foramen. 

C. Upper portion of bladder lying behind the 

pubes. 

D. Anterior cul-de-sac of the peritoneum. 

E. Body of uterus. 

F. Posterior cul-de-sac of the peritoneum. 

G. Peritoneal coat of rectum forming posterior 

wall of the posterior cul-de-sac. 
H. Rectum. 

I. and J. Labia majora and minora. 
K. Right genito-crural fold. 
L. Meatus urinarius. 



M, M. Anterior and posterior walls of vagina. 

N, N, N. Opening made through outer wall of 
tumor to show the relations of the parts 
within. 

0. Os uteri. 

P. Base of the bladder forming part of the tu- 
mor. 

Q, Q. Elongated and hypertrophied cervix uteri. 

Q'', Q''. Outline of lower part of bladder. 

R. Body of uterus also elongated. 

S, S. Dotted line showing the course of the in- 
cisions. 

T. Perinaeum. 

U. Anus. 



The accompanying woodcut is copied from the work of M. 
Huguier, and is as good a representation of the present case as 
if taken from the actual subject. 



HYPERTROPHY OF CERVIX UTERI. 299 

In connection with this case, the following one of hyper- 
tropic elongation of the cervix, and enlargement of the os uteri, 
together with fibrous tumors of the bodj of the organ, may be 
mentioned : — 

Case CLXXIX. — Ilijpertrophy of Cervix Uteri. — A 
widow lady, 48 years old, and the mother of one child, came 
under my care at the Massachusetts General Hospital in May, 
1863. Fifteen years before, she discovered a small tumor 
in the left side of the abdomen, which gradually increased 
in size, attended with a sensation of weight and bearing down, 
but without acute pain. This was followed a year after by 
a paralytic attack of the left side of the body, from which 
she partially recovered. Profuse flooding had occurred several 
times during the four or five months immediately preceding 
her admission to the Hospital, materially diminishing her 
strength. She experienced much difficulty in passing urine, a 
fact easily explained by the displacement of the uterus and sur- 
roundino^ oro-ans. 

She was a good deal emaciated, but had a fair pulse, and was 
able to take some exercise out of doors every day. The abdo- 
men was enlarged, and of a conical form, from the presence of 
a tumor of about twice the size of a cocoa-nut. An elongated 
tumor, nearly three inches long, and of about the same circum- 
ference, projected between the labia. This tumor, which might 
at first sight have been mistaken for a simple prolapsus of the 
vagina, consisted in reality of the elongated and hypertrophied 
cervix and os. The meatus urinarius opened upon the upper 
and front part of the tumor. The boundary between the tumor 
and the coats of the vagina was marked by wrinkles of the 
mucous membrane. A careful exploration of the abdomen dis- 
closed two tumors, one above the other, which together filled 
the cavity of the pelvis, and encroached on the rectum. Simp- 
son's sound could be passed but a short distance into the os : 
the finger was arrested at the os internum ; but the obstacle was 
easily overcome by the use of a sponge tent, and the finger then 
passed readily into the small cavity of the organ. 

A consultation with several gentlemen distinguished in the 



300 FEMALE GENITO-URINARY ORGANS. 

obsteteric art resulted in a decision unfavorable to any operative 
interference. 

The patient remained under observation in the Hospital about 
a fortnight, wdien she w^as seized with pains in the abdomen, 
and died with symptoms of peritonitis. 

On post-mortem examination, a large intra-mural tumor was 
discovered, obliterating nearly the whole cavity of the uterus. 
This was the tumor which had been felt immediately above the 
pubes. The second tumor, which had been felt above the first 
one, was attached to the exterior wall, directly over the other, 
and was connected with the uterus only by a small pedicle. A 
third tumor, of the size of a pigeon's egg, was found near the 
upper part of the cervix, making its way into the cavity of 
the uterus, and might probably, after a time, have made its ap- 
pearance through the os, and thus have come within reach of a 
surgical operation. The external tumor proved, as had been 
supposed, to be the os and the greatly elongated and hyper- 
trophied cervix, which, had there been no other disease to forbid 
it, might have been removed as in the case just related. 



OVARIOTOMY. 

The extirpation of large ovarian tumors has been occasion- 
ally practised for a long time. Within a few years, the opera- 
tion has been revived in England and in tliis country with 
remarkable success ; many patients, otherwise doomed to a lin- 
gering death, having been completely cured by it. The great 
obstacle to the more free performance of ovariotomy is the hesi- 
tation which the surgeon feels to advise, or even to permit, a 
patient in the enjoyment of moderate health to undergo an 
operation which may almost immediately prove fatal. In itself, 
ovariotomy is not more dangerous than many of the recognized 
capital operations ; the difference being, however, that these last 
are done in a pressing emergency, while ovariotomy generally is 
not. The proper course of practice would therefore seem to be, 
to make a fair statement to the patient and friends of what they 
have a right to expect from the operation, leaving them to 
decide for themselves. I have once been completely successful 



OVARIOTOMY. 301 

in the treatment of an enormous unilocular cyst of the ovary, 
in which respiration was impeded, the limbs oedematous, and the 
patient rapidly failing, by evacuating the cyst, and leaving the 
canula in j)osition ; making occasional use afterwards of iodine 
injections, to correct offensive discharges. 

One point to be especially noticed in the manner of perform- 
ino' ovariotomy is the method of securlnor the bleedins; ves- 
sels of the pedicle. The plan now most in favor is by drawing 
the stump out of the wound, and compressing it in a clamp 
made for the purpose. This proceeding, however, is sometimes 
followed by severe pain after the operation, especially if there 
is much tension of the parts. Professor Simpson, of Edinburgh, 
has lately recommended " acupressure " as a substitute for the 
clamp, and claims for it substantial advantages. 

Although it seems almost superfluous to give the precaution 
not to mistake pregnancy for ovarian tumor or dropsy, yet I am 
led to do it from the fact that such mistakes do occur. The 
differential diagnosis is not always easy between ovarian tu- 
mor and pregnancy, and we should remember that they may 
co-exist. I have heard of instances where the abdomen of a 
pregnant woman has been punctured for supposed ovarian drop- 
sy. The following cases in my practice are adduced as illustra- 
tive of the subject : — 

A patient applied to me, who said she had a tumor appear 
under her ribs immediately after her last confinement, and at 
the end of nine months — when I saw her — her abdomen was 
immensely distended. She said that she had been advised an 
operation. Not having the time to examine her, I sent her 
to a friend distinguished in the obstetrical art, who informed 
me, that, after a thorough examination, he found pregnancy 
existing, with a great superabundance of amniotic fluid. She 
was confined very soon after, with a healthy child. In a case 
of supposed ovarian disease, sent to me from a great distance 
for operation, the symptoms had been anomalous, and such as 
early to lead to the suspicion of tumor. On auscultation, I 
heard the sounds of the foetal heart. It is very possible that 
pregnancy in this, as in the next case, had supervened on the 
original tumor. In a third case, and one which would be much 



302 FEMALE GENITO-URINARY ORGANS. 

more likely to lead to error, a woman applied at the Hospital 
with an ovarian tumor of one side, of eighteen months' standing. 
She was treated by the internal administration and external ap- 
plication of iodine. She applied once or twice afterwards, at 
intervals of two or three months, the tumor gradually enlarging. 
Finally, having delayed for six or seven months, a tumor, which 
was supposed to be the same, was found, filling the whole 
abdomen. She was shortly after confined, and since then I 
have not heard from her. 

Case CLXXX. — Large Ovarian Cyst. Puncture. Ca- 
nula left in the Wound. Cure. — A married woman, aged 
41 years, entered the Hospital, March 1, 1860, with a large 
ovarian tumor filling the entire abdomen, pressing up the ribs, 
and encroaching so much upon the cavity of the chest, as to 
cause great difficulty in respiration. The limbs were in a 
highly edematous state, and she was in a very feeble condition 
and rapidly failing. 

The tumor began fourteen months before, and increased 
gradually until it measured four feet in its greatest circumfer- 
ence. 

As it was suspected that the tumor, which was uniformly 
elastic and fluctuating, was unilocular, it was decided to punc- 
ture it with a large trocar, and leave the canula in the wound. 
This I did March 4th, and drew off eighteen quarts of light, 
straw-colored fluid. The canula was left in the wound, and 
secured there. March 10th, the plug was removed from the 
canula, and a pint and a half of fluid escaped, thicker and more 
gelatinous than that drawn first. March 19th, the discharge from 
the canula was thicker, and somewhat of a purulent character. 

In April, from exposure, a sudden swelling of the abdomen 
took place, with considerable tenderness, attended by a febrile 
attack, the discharge from the sac becoming somewhat offensive. 
A weak solution of iodine was thrown in with good effect, and 
corrected the offensive state of the secretion. Constitutional 
and local means were also used to allay the irritation. 

April 28th, the sac had contracted very much, so as to form 
quite a small tumor in the abdomen. All the symptoms de- 



VESICAL CALCULUS. 303 

tailed above — such as difficulty in breathing, dropsy, &c. — 
were completely relieved ; and she left the Hospital in an improv- 
ing condition. I heard from her a year afterwards, quite well 
and stout. 

The sac then formed a small, hard tumor, about the size of a 
billiard-ball, on the left side of the abdominal cavity. 

VESICAL CALCULUS. 

Case CLXXXI. — Large Vesical Calculus in Female, 
filling the ivhole Bladder. Lithotrity . Recovery. — In 
June, 1865, a woman, 36 years of age, entered the Hospital 
under the care of Dr. Francis Minot, in an extreme state of 
emaciation, suffering from disease of her bladder. Dr. Minot 
sounded her, and, detecting a stone, referred her to me. It 
seems that, twelve years before, after the birth of twins, mictu- 
rition became painful and frequent, and the urine was mixed 
with blood. The symptoms were then alleviated until her 
second pregnancy, when they returned. For the last eight 
months, these symptoms had been constant, confining her to 
her bed, with a degree of pain requiring the constant use of 
large doses of morphine. She had no power to retain the 
urine, which dribbled away, mixed with mucus, pus, and blood. 
On a chemical examination, it was found to be very strongly 
alkaline, containing a thick, ropy deposit, with some albumen. 
Under the microscope, many blood and pus corpuscles, epithe- 
lial scales, and crystals of the triple phosphates, were observed. 

On sounding the bladder, it was found nearly filled Avith an 
immense calculus. 

A question arose in this case as to the choice, considering her 
feeble state, between lithotrity and lithotomy. It was decided 
that this should depend upon the hardness of the stone. 

She was etherized, and the stone seized with the lithotrite in 
its shortest diameter. The screw was applied, and the stone 
easily crushed ; the fragments were seized twelve times with 
great rapidity, and thoroughly broken up. The debris was 
then seized with a large, spoon-billed female lithotrite, — which 
I had contrived to work with one hand, — for operating in the 



304 FEMALE GENITO-URINARY ORGANS. 

female bladder ; the other hand being occupied in the vagina in 
supporting the bladder, and guiding the fragments into the jaws 
of the instrument. For three or four days after the operation, 
no fragments escaped, although there was a great sense of relief. 
At the end of a w^eek, the operation was repeated with the 
female lithotrite, and a great quantity of fragments removed. 
At the end of another week, it was again repeated under ether, 
and the bladder to all appearance effectually cleared. The 
stone, in its largest circumference, must have been at least six 
inches. The patient, from a state of exhaustion and constant 
suffering, was, at the end of five weeks, restored to better 
health than she had ever before enjoyed. Two months after the 
first operation, a second was required to remove a small frag- 
ment which remained. 



RENAL CALCULUS. 

Case CLXXXIL — Calculus in the Kidney^ with a Fis- 
tiiloiis Opening, supjoosed to he Ccnnous JBone, Death. 
Autopsy. — A widoAv, aged 45, entered the Massachusetts 
General Hospital, Oct. 1, 1858, with what was supposed to 
be caries of a lower rib or of the transverse process of one 
of the vertebrae. Thirteen years before, she had fallen down 
two pairs of stairs, and was supposed to have broken one of 
her ribs. She soon recovered sufficiently to be able to work, 
but still had constant pain in the side. Ten years after, the 
pain increased, attended with swelling, and an abscess formed 
in the loins just below the last rib, which was opened, and a 
quantity of pus evacuated : a fistulous opening remained ; and, 
w^hen she entered the Hospital, it was recorded, that dead bone 
could be felt by the probe. 

Oct. 3d, a sponge tent was introduced, and the opening grad- 
ually enlarged. 

Oct. 16th, the patient was etherized, and the surgeon in 
charge made a small incision so as to facilitate exploration. No 
bone could be detected. This examination was repeated on the 
2 2d, at which time the discharge from the wound was consider- 
able. 



RENAL CALCULUS. 305 

Nov. 8th, she came under the care of another of the sur- 
geons. No dead bone could be found with the probe ; but on 
Dec. 20th, the patient being etherized, an incision was made, 
and bone was supposed to be felt, but could not be removed. 

March 12, 1859, she came under my care. A bent probe 
was passed deep into the wound, and, being carried under the 
rib, occasionally struck what appeared to be bone divested of 
periosteum. All the other surgeons present probed the wound ; 
and the conclusion arrived at was, that the substance felt was 
too deep for a portion of rib, but probably was the transverse 
process of a vertebra in a carious condition. 

From the depth and circuitous route at which the substance 
was reached, and the great solidity of the surrounding textures, 
which had been so long inflamed, it was found quite impracti- 
cable to seize the supposed bone. The opening was therefore 
dilated by powerful forceps, free incisions being out of the ques- 
tion, from the dano^er of cuttino^ into the thoracic or abdominal 
cavity. The attempt at removal was necessarily discontinued 
for a time, as, from the very feeble condition of the patient, the 
administration of ether, probing, or any unusual interference, 
was accompanied by great depression of the pulse and excessive 
prostration. 

The patient had a very yellow, almost jaundiced, complexion, 
through the whole duration of the treatment, with little or no 
appetite, bowels excessively constipated, and a constant nausea. 
The urinary secretion was very scanty and disturbed. An 
attack of nausea and vomiting always followed the use of the 
probe, so that I was very averse to interfere with the wound, 
and avoided doing so unless strongly solicited by her. 

April 12th, she had severe pain in the side, which was a little 
relieved by opiates. 

On the night of the 21st, there was severe pain in the bowels. 
During the morning of the 2 2d, she was very weak, with con- 
siderable tympanites. She failed rapidly, and died in the 
evening. 

The autopsy was made by Dr. Ellis. '^^The pleurae, lungs, 
and heart presented nothing very remarkable. The perito- 
neum, omentum, and other parts, were reddened ; and a large 



306 FEMALE GENITO-UEINARY ORGANS. 

quantity of pus was found in the cavity of the peritoneum. 
The large intestines were quite firmly adherent in the left lum- 
bar region. 

" The seat of the left kidney was occupied by a dense mass of 
fibrous and adipose tissue. The cut surface of this presented, 
for the most part, the same appearance as the exterior ; but in 
the centre was a portion of reddish substance, perhaps an inch 
in diameter, and near it others of smaller size. Within this was 
a smaller cavity, lined with a serous membrane. This resembled 
the pelvis, and was occupied by an irregular, branched calculus, 
of small size, of a yellowish white color, and laminated. It 
was retained in its position by one or more prolongations. At 
the part which adhered to the posterior wall of the abdomen was 
an opening through which a probe passed into the cavity, and 
came in contact with the calculus. This opening was, undoubt- 
edly, continuous with the sinus known to exist before death ; but 
the point was not investigated until after the separation of the 
kidney. Nothing was noticed indicative of recent inflammation 
having its origin in this part of the abdomen. There was no 
caries of any bone ; but the sinus ran just below the last rib, 
which could be touched by a probe. 

"What appeared to be the remains of renal substance was 
examined by the microscope ; but the infiltration of fat globules 
made it impossible to distinguish any thing else. There was no 
trace of healthy tissue. 

" The cortical substance of the right kidney had an unusually 
white appearance." 

ABSENCE OF YAGINA AND UTERUS. 

Case CLXXXIII. — Absence of Vagina and Uterus, — A 
very delicate and intelligent young woman, 21 years of age, 
applied to me in March, 1860, and after some hesitation in- 
formed me that she had never menstruated ; and that, an 
examination having been made by some female physician, she 
had been informed that a malformation existed about the organs 
of generation. To my question, whether any symptoms ever 
occurred of a disposition in the menstrual secretion to establish 



ABSENCE OF VAGINA AND UTERUS. 307 

itself, she said that, when about fifteen years of age, she was 
seized with violent pains in the back, loins, and legs, which 
recurred, and kept up at intervals for the space of two or three 
weeks ; and that she was informed by her physician, that it was 
probably an attempt of the system to establish the regular 
monthly periods. This attack, however, passed off without the 
menstruation making its appearance ; and there had never been 
any indication of the performance of that function since, or any 
vicarious discharge elsewhere to take its place. 

On a partial examination at this time, with the patient lying 
on her side, I felt, in the usual situation of the vagina, a small 
opening, into which the probe passed up readily three or four 
inches. I therefore, perhaps too hastily, informed the patient, 
that the rudiments of a vagina existed, though quite small, and 
could probably be enlarged by an operation. I made no farther 
examination at the time, but could not explain why the men- 
strual fluid should be retained while the passage existed, which, 
though very small, must apparently lead up as high as the 
uterus ; and at the same time why there was no tumor, and 
none of the usual suffering attendant on retention of the 
menstrual fluid within the uterus. The patient, having no con- 
venient place in Boston for the operation, decided to enter the 
Massachusetts General Hospital , which she did about two weeks 
afterwards, when she was etherized, and a thorough investiga- 
tion made of her case. 

On ocular inspection of the external organs, I at once found 
that I was mistaken as to the existence of any opening into the 
vagina. The opening, in fact, which I had taken for it, was 
that of the urethra displaced from its usual situation below the 
pubes to a point about the centre of the vulva, perhaps an inch 
in front of the anus. A catheter being introduced through this 
aperture, the contents of the bladder flowed freely out. The 
catheter being left in the bladder, a finger, introduced into the 
rectum, came at once in contact with the instrument ; the vagina 
being absent, and nothing but the coats of the rectum and 
bladder intervening. The finger being now passed higher up, 
and hooked, as it were, into the cul-de-sac of the peritoneum, 
no uterus could be discovered ; but its place was occupied by a 



308 FEMALE GENITO-URINARY ORGANS. 

cord somewhat larger at the centre than sides, and this cord 
being followed up, at the distance of two or three inches from 
the central portion, a body could be felt about the size of a 
common garden bean. The patient in other respects seemed to 
be well-developed and perfectly formed. 

The announcement of the actual state of the case to her caused 
great distress. As it was of importance to discover whether 
the usual sexual peculiarities existed, I made, with as much 
delicacy as possible, some questions on this point ; to which 
she replied, that she had always considered herself a woman in 
every respect. 

I made a second exapiination of the case some days after- 
wards, with the patient in the erect position, thinking that, if 
any uterus were present, I should thus be more likely to detect 
it than if she were on her back, but with the same result as 
before. 

In a late number of Guy's Hospital Reports, an interesting 
case is given of absence of the vagina, where the uterus became 
80 distended by the menstrual fluid as to require an operation. 
When the patient was first examined, the surgeon passed his 
finger into a passage supposed to be the vagina, but which he 
soon discovered to be the dilated urethra. The uterus was 
punctured through the rectum to the entire relief of the patient, 
the aperture remained open, and she was heard from afterwards 
as having the menstrual discharge regularly through it, and 
without any difficulty. 

Case CLXXXIY. — Complete Absence of Vagina and 
Uterus. — April, 1858, a patient supposed to have an occlu- 
sion of the vagina was sent to me by a medical friend. She 
was 25 years of age, well developed, about five feet two or 
three inches in height, and had been married four years. She 
had never menstruated ; and it may be mentioned, that her 
mother did not menstruate till the age of twenty-one, after 
she had been married one or two years. 

On examination, I found what at first appeared to be a very 
small vagina, which would only admit, with much suffering to 
the patient, the little finger. The sensation imparted was as if 



ABSENCE OF VAGINA AND UTERUS. 309 

the finger had passed through the tissue of an old cicatrix. 
Supposing this to be the vagina contracted from some inflamma- 
tory process which had occurred at an early period of life, she 
was advised to go into the Hospital for farther investigation. 
Having entered, after the lapse of a few days, she was ether- 
ized previous to an examination, both to save her feelings on 
the score of delicacy, and also to allow of any surgical opera- 
tion, if one should be deemed necessary. 

On inspection, the breasts were found to be well developed. 
The external organs of generation, the clitoris, nymphse, &c., 
were normal ; there was hair on the pubes. In the situation 
usually occupied by the vagina was an aperture large enough to 
admit the little finger. No urethra could be found ; and this 
aroused suspicion as to the true nature of the case. The finger 
was now passed into the canal, and the other hand being placed 
on the external walls of the abdomen, it was evident that both 
coverings, or rather both walls of the bladder, were not em- 
braced between them. The finger being withdrawn, and a 
catheter introduced, the urine at once flowed through it, show- 
ing conclusively that this was the bladder, and that the finger 
had been passed through the dilated urethra. The finger being 
introduced again as before, and a finger of the other hand 
passed into the rectum, no traces of vagina or uterus could 
be found ; while the forefinger of the left hand in the rectum 
could be hooked, as it were, into the cul-de-sac of the perito- 
neum, and this dragged down nearly to the anus. 

From the result of this examination, it was at once evident 
that no surgical operation could be of any benefit. I was dis- 
posed, however, to keep her under observation until the next 
menstrual effort, which, according to her account, took place 
monthly, and was announced by pain in the back lasting four or 
five days. In case any rudiment of the uterus existed, it was 
thought probable it would be manifested at that time. She 
was therefore advised to remain In the Hospital to afford further 
observation of the case. Nothing however was discovered bear- 
ing the least resemblance to a uterus. 

During the four years of her marriage, so far as I could learn, 
a veiy partial indulgence in sexual intercourse took place, which 



310 FEMALE GENITO-URINARY ORGANS. 

resulted, probably, in the great dilatation of the urethra which 
was observed. 

The above case is interesting from the fact, that the patient 
presented perfect external development, accompanied by the 
usual sexual feelings, with a complete absence of two of the 
important organs engaged in the sexual functions. It may be 
added that no vicarious discharge of any description supplied the 
place of the menstrual secretion. 

In one or two instances which have fallen under my notice 
when the vagina and uterus were wanting, the urethra was 
placed lower down, as in the above case ; and, instead of occupy- 
ing its ordinary situation, it formed a continuation of the rudi- 
mentary vagina. 

A case of entire absence of menstruation in a young woman 
may here be mentioned, who consulted me some years since. 
A sound was passed into the uterus, but no obstruction was de- 
tected. This patient had a vicarious bloody discharge from the 
rectum once in six weeks, lasting some days. Development 
and sexual feelings were normal. 



HERM APHRODISM . 

Case CLXXXV. — Suijposed Encephaloid Testicle, 
Operation. Death. Autopsy. Hermaphrodism. Disease 
proved to have heeii Ovarian Tumor. — A person giving the 

name of Thomas M , 21 years of age, applied to me in 

April, 1859, on account of a great enlargement of what appeared 
to be the right testicle. His external appearance was that of a 
young working Irishman. The beard was full, strong, and 
black, the larynx of the ordinary size, and the voice masculine ; 
the shoulders were broader than the hips ; the muscles were 
well developed ; height sixty-five inches, of which thirty-three 
were above the pubes, and thirty-two below. 

The patient's own history of the case was as follows : Early 
in life he lost, or had had removed, the left testicle, but could 
give no particulars of it. This account was probably falla- 
cious. 

The right testicle was greatly enlarged, measuring thirteen 



HERMAPHRODISM. 311 

inches in circumference, seven and three-quarters in length, 
egg-shaped, and extended nearly two-thirds of the distance from 
the pubes to the knee. It was excessively tense, hard, and 
seemed too heavy to be supposed a hydrocele, although the 
great evenness of its surface seemed to make such a supposition 
probable. There were large veins on its surface. What seemed 
to be the spermatic cord was well defined above the tumor, 
though a little harder than natural. There was considerable 
complaint of pain in the back and loins, which was attributed to 
the dragging weight upon these parts. The pain in the tumor 
itself was not excessive. The testicle had been, he said, of 
normal size till about a year before, when he received a severe 
kick upon it. After the first acute symptoms had subsided, it 
began to swell slowly ; but within the last month it had in- 
creased very rapidly. The sexual feelings and power of erec- 
tion continued natural till six weeks before I saw him, and 
since then they had completely disappeared. He never had 
sexual intercourse. About a month since, both breasts began 
to swell and become painful ; and, upon examination, I found 
them to be of the size of those of a young female : the glandular 
structure could be distinctly felt, and the disk was about four 
inches in diameter. No fluid issued from them on pressure. I 
could not learn from him whether they had previously been 
larger than natural ; but the present increased size seemed to 
have corresponded in time with the loss of sexual desire. He 
stated that his health was failing, he had lost his appetite, and 
was desirous of an operation to relieve him from suffering. 

He was sent to the Massachusetts General Hospital, where 
the tumor w^as removed on Wednesday, April ISth, and the 
supposed cord tied en masse near the abdominal ring ; some 
dissection being necessary iri order to reach it above the disease. 
Previous to the operation, he had been excessively diffident 
about having the genital organs examined, and at this time the 
following appearances were first remarked. The glans penis 
appeared normal, but imperforate ; the body of the penis was 
from two to three inches in lenoth. Commencins: about an 
inch from the glans, and extending to within two inches of 
the anus, was a fissure having on each side two flaps of delicate 



312 FEMALE GENITO-URINARY ORGANS. 

epithelium, exactly resembling the nymphge, which, being sepa- 
rated, presented, as it were, the external organs of the female. 
At the lower part of this fissure commenced apparently the ure- 
thra ; and, an instrument being introduced about three inches, 
water escaped freely. External to the fissure, the skin was 
thin and delicate, like that in the neighborhood of the female 
organs of generation. The pubes was very fully covered with 
hair, which was shaved to facilitate the dressing after the opera- 
tion. Dr. Dyer, house-surgeon of the Hospital, at my request 
took a cast of the breasts, their appearance was so unusual. 
My inquiries would have been much more particular in regard 
to the previous history, and especially as to any thing resem- 
bling the menstrual discharge, if I liad had the slightest suspi- 
cion of the patient's sex. 

The day after the operation, the patient complained a great 
deal of pain in the abdomen, and much fever, also of thirst, 
which was partly attributed to the ether administered. The 
febrile action gradually increased from day to day ; the swelling 
and pain in the abdomen, however, subsiding until death, which 
took place on the seventh day after the operation. 

An examination of the body was made on the following day. 
Both lunofs were found studded with laro^e masses of cancerous 
matter, and were adherent at certain points to the pleuras. The 
liver at first appeared healthy ; but, on being cut into, a number 
of cavities were discovered about the size of a filbert, containing 
a thick milky fluid. On the spine, at the root of the mesentery, 
was a mass of enlarged lymphatic glands, the chain of them 
extending down from the edge of the rim of the pelvis nearly to 
the groin, much flattened, and not perceptible through the walls 
of the abdomen. The neighborhood of the ring, just above the 
spot where the ligature had been applied, was in a gangrenous 
condition. The intestines being removed, exposed the follow- 
ing remarkable appearances in the pelvic organs : The bladder 
was somewhat distended, and just behind it lay a well-formed 
uterus of natural size, as in the unimpregnated state. On the 
left side of the uterus, the Fallopian tube terminated in its fim- 
briated extremity, under which lay the ovary, rather smaller than 
natural, and with one or two little bands of adhesion running 



HERMAPHRODISM. 313 

between it and the Fallopian tube. The ovary, being incised, 
displayed its ordinary structure. On the right side, the tube 
ran along under the peritoneum, turned upwards, and was lost 
in a diseased mass in the right groin. The parts were now 
removed with great care from the pelvis by Professor J. B. S. 
Jackson. 

All the pelvic organs being removed, and placed on a table, 
we proceeded to investigate the relation of the different organs. 
A probe was passed into the urethra, and went readily into the 
bladder : being withdrawn, and depressed a little, it passed 
with equal facility to the fundus of the uterus. The parts were 
now turned over, and the back of the vagina and uterus laid 
open. The vagina, which commenced about an inch from the 
external orifice, was nearly four inches in length, and terminated 
in the os uteri ; which, however, did not make much of a relief 
in the vagina, although the distinction in the two textures was 
fully marked. The arbor vit^e was very distinct, and beautifully 
shown : it extended nearly up to the fundus of the uterus. The 
blowpipe being introduced into the left Fallopian tube, air 
passed freely through it, and out of the fimbriated extremity. 
A probe could be passed for a certain distance freely in the right 
Fallopian tube, but air did not pass through it as in the other. 

In regard to the tumor removed, the whole substance of it 
seemed to be converted into encephaloid matter, and its natural 
structure lost. The external covering was adherent, except at 
its anterior part : it was cut into early in the operation, and 
about a gill of a yellow-colored serum escaped ; exposing, on 
the upper part of the organ, a collection of beautifully colored 
cysts, of all sizes, like a mass of brilliant crystals. 

It would have been extremely interesting in this case to have 
decided whether menstruation had ever -taken place through the 
urethra ; but this, unfortunately, I had no means of determin- 
ing. 

The organs being given to Dr. Hodges, the demonstrator of 
anatomy to the college, for the purpose of a more minute dis- 
section and investigation, he kindly furnished the folio win or 
report : — 

40 



314 FEMALE GENITO-URINAKY ORGANS. 

" Pilous development that of a male. Penis, which is that of an 
adult, and not of a youth, measures along its dorsum two and a half 
inches. The glans, of proportionate size, is covered, except in the 
immediate vicinity of where the frsenum should be, by a well-developed 
prepuce. The urethra being cleft from the meatus backwards, the 
prepuce is not completed underneath, but becomes lost in the sheath of 
the penis. 

" The urethra is traceable, along the under surface of the penis, from 
the meatus 3^ inches, and disappears in an orifice 2^^^ inches in front 
of the anus. Throughout this distance, it consists only of a fissure, or 
sulcus, the sides of which, having irregular borders, are in apposition. 
It is lined with well-characterized mucous membrane ; and has, at vari- 
ous points, distinct lacunre. 

" Diverging obliquely upwards and outwards from the sides of the 
urethra are folds of integument, constituting distinct labia majora and 
minora. On the left, at the side of these labia, are indistinct marks of 
cicatrices. 

" Examined internally, the penis consists of two corpora cavernosa, 
measuring from the meatus to their bifurcation 4 inches. They ter- 
minate in well-marked crura ; and the nerves, arteries, and veins of the 
dorsum of the penis, have the usual size and position. The corpus 
spongiosum is well developed, but split longitudinally into two halves, 
which are to be seen on either side of and behind the corpora caver- 
nosa, and correspond externally to two folds which form the labia 
minora. 

" Cowper's glands were not found. 

" The muscles of the perinasum were somewhat confused, but the 
following were distinctly made out: erectores penis, compressores 
urethrse, levator and sphincter ani ; anterior to the latter was another 
elliptical sphincter muscle, corresponding, probably, to the sphincter 
vaginae. The transversus perinei, as such, was not made out. 

" The bladder is of ordinary size, but its muscular development is 
greater than usual. It has two ureters, normal as to their entrance and 
otherwise. From the internal orifice of the bladder to the 'vagina 
urethralis ' it is 1^ inch. Laid open along its anterior surface, its neck 
is embraced by a bi-lobed prostate gland of about half the natural 
adult dimensions ; posteriorly to this, the neck is thickened, and the 
section is as through a structure resembling the prostate. On squeez- 
ing the prostate, its secretion is seen to issue through several apertures 
on each side of the urethra, where the prostatic sinus usually exists. 
There is no verumontanum ; but where it should be, and where the sinus 
pocularis would be found, the urethra and vagina blend, and a probe 



HERMAPIIRODISM. 315 

inserted and passed backwards enters the vagina ; passed forwards, it 
appears externally at the orifice in front of the anus. Behind the 
bladder are found the uterus and vagina. On dissecting up the bladder 
from the vagina, as far down as the prostate, no vesiculce serainales are 
to be found. 

'' The uterus and vaghia are 5| inches in length. The uterus, 2^- 
inches long and ly^g inch wide at its widest part, consists of fundus, 
body, neck, and os. The neck has unusually well-marked arbor vitas. 
Just within the os, the mucous membrane appears abraded. The body 
has a triangular cavity, into which the Fallopian tubes enter by large 
orifices. The vagina, 3f inches long and li inch wide, is rugous, 
especially near its termination anteriorly, and has distinct columns. 
Anteriorly it contracts to terminate in the canal common to it and the 
urethra, and at this point has a sufficiently well-marked hymen. 

" The Fallopian tube of the right side permits air to be blown through 
its whole length. Near its termination in a fimbriated extremity, it 
becomes a little convoluted and dilated. Its length is 3| inches. At 
a distance of 2^ inches from the uterus, on the left side and in its usual 
position, is an ovary with a lobulated surface. 

" The broad ligament on each side e^xists as in an ordinary female 
uterus. On the left side, the round ligament is to be seen diverging 
from the broad, and pursuing, so far as traceable, the usual course 
which it would pursue under ordinary anatomical conditions. On the 
right side, the Fallopian tube admits the passage of air only for a cer- 
tain distance. Near the uterus, it is of large size ; but it soon diminishes 
and becomes smaller. It is traceable to the point at which the ' cord ' 
of the tumor was divided, and is accompanied by the round ligament in 
its whole distance ; no appearance indicating the usual divergence of it 
from the Fallopian tube on the anterior surface of the broad ligament. 
No ovary is found on this side. 

" The rectum lies behind the uterus, and is in all respects normal." 

Dr. Ellis, microscopist to the Hospital, gives us the follow- 
ino' results of his investio-ation : — 

" Examined with the microscope, the breasts were found to be com- 
posed of fibrous tissue, and a few small nuclei. No lobules were seen. 

" The mass removed before death consisted of two parts, the largest 
of which was rounded and solid ; the other was composed of cysts. The 
former w^as 4^ inches long, 3^- wide, and 2^ thick; the latter, two or 
three inches in diameter. On close examination, nothing like a vas 
deferens could be found ; but at one part were a number of parallel 
bloodvessels." 



316 FEMALE GENITO-URINARY ORGANS. 

Hemarlcs. — The Internal organs, in the case we have been 
considering, seem evidently to belong to the female sex, with 
the exception of the prostate gland. The importance of this as 
connected with the male sexual organs has diminished in the 
eyes of distinguished philosophical anatomists who have lately 
written on the subject, being considered as much an appendage 
to the urinary organs as to the sexual. We therefore, with 
some difficulty, account for the impetus given to the external 
male organization, beard, larynx, penis, and general masculine 
formation of the body ; and the views we have entertained in 
regard to the effect of the sexual organs on the external charac- 
ter seem to be very much disturbed by the present case. It 
might be very interesting to trace the analogies between different 
organs in the male and female systems, which are suggested in 
this instance ; but we will refer to the very thorough and inter- 
esting paper of the distinguished Professor Simpson, of Edin- 
burgh, on hermaphrodism, in the second volume of his obstetric 
works, edited by Dr. Priestly of Edinburgh, and Dr. Horatio 
R. Storer of Boston, where this whole subject has been most 
fully elaborated, and we may almost say exhausted. 

In connection with the above case, I append the following, 
reported by me to the Boston Society for Medical Improvement, 
in May, 1857, and extracted from their records : — 

" The subject of this very uncommon deviation from nature was 25 
years of age, born in Maine, of healthy parents. He was by occupa- 
tion a sailor ; and the appearances to be described were only discovered 
when brought to the prison, where, on being undressed to put on the 
prison clothes, he was thought, from the large size of the breasts, to be 
a female in disguise, and was therefore transferred to the surgeon of 
the institution. Dr. Morris, for examination. On my visit to his cell, 
he seemed to have no objection to an examination, when it was ex- 
plained to him that it was for a scientific object. 

" Beginning with the face, the features are soft, and the expression 
mild ; there is no beard. The neck is of medium size and length, but 
rising toward the back, as in the female. The shoulders are sloping, 
round and smooth, the muscles not being prominent. The upper ex- 
tremities are delicate, and the hands small. The breasts, which are 
the most striking feature in this person, are large, well-developed even 
for a female, quite handsomely formed, with large blue veins running 



HERMAPHRODISM. 317 

over them, as in a nursing woman ; the nipples being large, with a broad, 
dark areola. The abdomen is quite prominent ; the navel deep ; the 
hips very broad, as in the female. There is a small penis. The scrotum 
and testicles are very small, the size of the latter being that of a bean. 
The legs are short, the middle of the body being, by measurement, half 
way between the umbilicus and the pelvis, instead of being, as in the 
male, at the pubic region. The voice is masculine ; the sexual propen- 
sities normal. 

" The remarkable feature of this case is the fact of the small male 
organs of generation implanted on a body almost entirely female. Cases 
constantly present themselves to the observation of medical men, of 
malformed genital organs, having the appearance of a combination of 
the male and female ; also of men with a large mammary organ. In 
this case there can be said to be no malformation." 



CHAPTER VIII. 
THE EXTREMITIES. 

FRACTURES. 

The great importance of these injuries, and the absolute ne- 
cessity, in most cases, of proper treatment, have given them 
a very prominent place in the surgery of all ages. From the 
earliest times of which we have any record, down to the present 
day, the treatment has been oscillating between the employment, 
on the one hand, of powerful engines for their reduction and 
retention in place ; and, on the other, of simple rest in an easy 
position. Both of these extreme modes of practice have been 
extensively employed within the past thirty years, and both have 
undergone great improvements. 

In my early practice, I was in the habit of laying great stress 
on an immediate and exact application of retentive measures : 
often, I now think, to the discomfort of the patient, and per- 
haps in deference to the prevailing opinion. I have since 
become convinced of the propriety of doing as little as possible 
for the first few days : and have generally been content with 
making a slight extension, so as to bring the broken ends of the 
bone together so far as they will come without violence ; then 
waiting until the irritability of the muscles has subsided, before 
proceeding to the application of the permanent apparatus of 
splints and bandages. In many fractures, where great immediate 
distortion is produced by muscular contraction, after a few days 
of rest, combined perhaps with gentle extension, the broken 
bones seem quietly to settle down into their proper places ; and 
the whole treatment, after the proper application of splints, 
resolves itself into careful watching, with occasional slight 
manipulations to remedy accidental displacements, and to prevent 
excoriation. 



FRACTURES. 319 

Professor Hamilton, of New York, by the exhibition of a 
great number of cases, treated with the best received apparatus, 
has laid the profession under great obligations, by showing that 
the perfect adaptation of broken bone, and a cure without de- 
formity, is the exception, and not the rule. To any one who 
takes a rational view of the question, it will easily be perceived 
that it is not the bone alone which is injured in cases of frac- 
ture ; but that the soft parts, such as periosteum, muscles, 
fascia, and integument, are more or less implicated. Swelling 
ensues ; and, even if it were possible to exactly discover the 
situation of the fractured ends, the manipulation is resisted by 
the patient. Ether, which of late years has assisted so much 
in the diagnosis of these cases, is not always at hand ; and, 
even if the bone is replaced with, its assistance, displacement 
may at once recur from the irritated muscles. Generally 
speaking, a slight inequality about the bones is of little conse- 
quence. Although looked on by the public as owing to a want 
of skill on the part of the surgeon, it is, in reality, unavoid- 
able ; and ultimately, In most cases, nature remedies any incon- 
venience caused by it. 

Fractures in the neighborhood of joints are always serious in- 
juries ; and, with few exceptions, are apt to be followed by more 
or less permanent deviation from the natural position of the 
bone or bones implicated. In fractures about the hip-joint, 
years may elapse before the lameness is overcome ; and, in 
many cases, it Is permanent. 

It is impossible to state exactly the time necessary for the 
union of a fractured bone. It depends on a number of circum- 
stances ; namely, the health of the patient, the manner in which 
the fracture was received, the parts injured which are afterwards 
engaged in the reparative process, and the treatment. In chil- 
dren, at the end of a month after fracture, I have often observed 
myself, and requested others to observe, perfectly dry crepitus 
that could be felt between the broken ends of the bone ; the 
limb, at the seat of the fracture, being firm, and, to all appear- 
ances, able to be used. 

Angular distortion after fractures should be treated, as soon 
as discovered, by gradually increased pressure, applied by means 



320 EXTREMITIES. 

of a straight splint and roller, or adhesive straps. It is worthy 
of remark, that very great deformity may be corrected in this 
way in young persons, even long after the receipt of the in- 
j^iry. 

Fracture of the clavicle is perhaps one of the most common 
of the injuries to bones, and is one of the most troublesome to 
treat according to the old complicated method. Many years 
since, the simple apparatus of Dr. Fox, of Philadelphia, was 
introduced by me into the Massachusetts General Hospital, 
w^here it continues to be used with some slight modifications. 
It consists essentially in a pad for the axilla and a bag for the 
arm slung from the well shoulder. Many cases of this fracture 
do well without especial treatment ; and we often see it already 
in a fair way to recovery in children brought to us for supposed 
lameness of the shoulder, resulting from a fall a week or two 
before. 

Frequently, from the swelling of the soft parts, the cellular 
membrane in the neighborhood of the clavicle being very loose 
and extensible, it is almost impracticable to discover the frag- 
ments. By placing the patient on his back, with perhaps a pillow 
between the shoulders, as the swelling subsides, the fragments 
will generally be found to have assumed as good a position 
as they would have done with the most elaborate apparatus. In 
comminuted fractures, the central fragment or fragments are 
usually beyond our control. In one instance, I have seen a 
sharp piece of the bone standing at a right angle between the 
outer ones, which could not be displaced by any justifiable force, 
and threatened to make its way through the integument. This 
was prevented by means of adhesive plaster, applied in such a 
way as to bring different portions of skin successively over it, 
and thus too long pressure at any one spot prevented. The 
sharp point was ultimately partly absorbed, and partly en- 
veloped in the callus ; and the patient recovered perfectly, with 
the exception of a very slight irregularity of the bone. The 
results of fracture of the clavicle are almost always favorable. 
In the very large number of cases which have come under my 
notice, I have never known union to fail except in one instance, 
— that of a sailor severely injured at sea by a fall from a mast, 



FRACTURES. 321 

and not subjected to treatment, the blow being a direct one at 
the seat of fracture. The ordinary shortening which occurs 
after this fracture does not seem to impair the power over the 
arm. 

The diagnosis in fracture of the condyles of the humerus, 
with dislocation of the fore -arm backwards, or in fracture 
of the humerus just above the elbow-joint, in the adult, is ren- 
dered very obscure by the swelling which almost immediately 
ensues. The fore-arm may usually be easily drawn into place, 
and the injury thus distinguished from a simple dislocation. 
Splints are borne with difficulty ; and it is necessary to keep the 
patient in bed, with the arm resting on a pillow, and apply 
cooling lotions to reduce the inflammation. When this is ac- 
complished, angular splints of wood, gutta-percha, or paste- 
board, may be used to steady the joint. This fracture, under 
the best treatment, is apt to terminate with more or less loss of 
power to flex and rotate the fore-arm. Ultimately, however, 
very serviceable use of the limb may be gained. The injury 
usually occurs from a direct blow^ ; and the inflammation of the 
soft parts in the neighborhood of the elbow is more severe 
than in simple dislocation which results from indirect violence. 
Fracture of one of the condyles of the humerus into the elbow- 
joint is very apt to be followed by adhesions and loss of motion. 
When there is luxation of the joint, in addition to the fracture, 
splints become necessary ; but should be removed, and passive 
motion begun, as soon as the tendency to displacement is over- 
come. 

Fracture of the lower end of the radius, which is of so fre- 
quent occurrence in winter, from a fall on the hand, is apt to 
be followed by deformity, and impairment of the motion of the 
part. I have treated this fracture, in many cases, with the 
simple and ingenious splint invented by Dr. Henry Bond, of 
Philadelphia. For facility of application, as well as for the 
comfort of the patient, it appears to me to ofler important 
advantages over any hitherto invented ; not excepting the fa- 
mous pistol-shaped splint of Nelaton, which, however, in some 
cases perhaps, may be found very usefid, especially in those 
attended with much lateral displacement. In Dr. Bond's splint, 

41 



322 EXTREMITIES. 

the hand grasps a wooden pad, the fingers being left free during 
the treatment, and sufficient motion allowed them to prevent the 
stiffness which is apt to take place where the arm and hand 
are confined by bandages between two splints. 

Fracture of the lower third, or small part, of the leg, is 
often difficult to manage, owing to a projection of the tibia 
which occurs, attended with more or less deviation of the leg 
from a straight line ; giving rise occasionally to lameness, by 
restricting the range of flexion of the ankle-joint. This devia- 
tion is best avoided by placing the limb upon a double inclined 
plane, applying extension and counter-extension by means of 
adhesive straps, fastened above by upright stanchions, connected 
with the leg. part of the apparatus, and below to the foot-piece. 
Where the skin is tender, and obnoxious to pressure, suspension 
may be tried ; the foot being well elevated. This fracture may 
also be successfully treated by the starched or plaster bandage. 
A slight degree of deformity is almost always left where there 
has been displacement in the beginning. 

For fracture of the fibula near the ankle, with displacement of 
the lower fragment, the powerful side-splint of Dupuytren ful- 
fils all indications. 

Transverse fracture of the patella, attended, as it often is, by 
great separation of the fragments, may be most successfully 
treated by position alone. This I tried at first with the body 
slightly bent, and the limb raised at a great angle from the bed. 
The effect of flexing the thigh so much was to render the 
patient very uncomfortable. I was therefore led, as an experi- 
ment, to place the limb perfectly flat on the bed, which I found 
answered better than the theoretical posture devised with the 
idea of more perfect muscular relaxation. The old methods 
for confining the upper fragment by bandages are always ineffi- 
cient, unless aided by a correct position of the limb, and are 
useless with it. They give rise to great swelling and much 
needless suffering, besides actually deranging the position of the 
fragments by so tilting them as to prevent their proper approx- 
imation. By the use of the ingenious steel hooks of Malgaigne, 
it is claimed that a still more accurate adjustment of the parts is 
obtained ; but the plan has found little favor in this country. 



FEACTURES. 323 

The instances of this fracture which have occurred in my prac- 
tice have been chiefly the result of direct violence, though quite 
a number of them were caused by muscular contraction alone. 
Twice I have met with fracture of the patella from the kick of 
a horse : one case did well under the use of a starched bandage, 
there being but little separation of the fragments ; in the other, 
the bone was broken into several pieces, and the knee-joint im- 
plicated, producing an inflammation which resulted in death. 

Transverse fractures of the patella are united by ligament, 
according to my observation, and perpendicular ones by bone. 
The latter leave no troublesome effects as a rule, the opposite 
being true of the former. 

Fractures of the thigh of late years, unless for some special 
reason, have been treated by the apparatus of Desault, modified 
by the late Dr. Flagg of this city. It consists essentially of a 
long outside and a short inside splint ; a band around the body 
with a perineal strap attached to it, for counter-extension, and 
a cross-piece below, uniting the outer and inner splints, with 
straps of adhesive plaster between for extension. The method 
of extension by bands of adhesive plaster, by which such good 
results are obtained, is due to Dr. Josiah Crosby of Manches- 
ter, X.H. I have employed successfully at the Hospital, 
within a few years, as have other surgeons of that institution, 
the plan proposed by Dr. Buck, of extension by means of a 
weight attached to the foot ; the thigh being supported by 
short padded splints, and the counter-extension obtained by a 
perineal strap. By raising the foot of the bed, the weight of 
the patient's body, in most instances, gives sufficient counter- 
extension. Dr. Swinburne, of Xew York, has modified Dr. 
Buck's apparatus by dispensing with the use of all splints for 
the thigh. Eversion is prevented by placing bags of sand 
by the side of the limb. The great advantage of this treat- 
ment consists in leaving the limb open to inspection. It must 
be said, however, that we can use this method only with in- 
telligent and perfectly docile patients. In very old and feeble 
persons, who frequently cannot bear even this slight restraint, 
the double inclined plane or fracture bed are to be preferred to 
any other apparatus, and permit a greater change of posture. 



324 EXTREMITIES. 

I have seen a few cases of oblique fracture of the lower part of 
the femur, just above the condyles, caused by a fall from a 
height, on the knee ; the uj^per fragment projecting up just 
above the joint, and resisting all efforts for its reduction. This 
was the result of perforation of the muscles by the upper sharp 
fragment. In Sir Astley Cooper's great work on Dislocations 
and Fractures, this is well depicted. The process of restora- 
tion goes on very slowly, and the result is that the fragments 
unite at an angle. It is possible, when the nature of the case 
is detected early, that the bone might be disengaged by mani- 
pulations under ether ; but the swelling caused by the injury 
ensues so rapidly, and is so great, that the exact condition of 
the parts is liable not to be recognized. 

In oblique fractures of the femur, except perhaps in very 
young children, more or less shortening always remains, even un- 
der the most skilful treatment. It is, however, generally so slight 
as to be of but little consequence, frequently not exceeding a 
quarter to a half inch ; in which case it is compensated for by 
a deviation of the pelvis. The time required for the union of 
a fracture of the thigh is usually stated at six weeks ; but it 
does not follow that the callus has become firm enough, by this 
time, to admit of the use of the limb in standing or walking. 
The too early use of a fractured limb is often followed by the 
gradual bending of the bone, resulting sometimes in consider- 
able deformity. If, for any reason, it is thought proper to 
allow the patient to rise from his bed at this stage of the treat- 
ment, the limb should be supported either by splints, or the 
starched or plaster bandage, and crutches used for a time. 

Patients with fracture or dislocation of the spine, the latter 
being seldom unaccompanied by the former, I have often treated 
in public and private practice ; and have a few times cut down 
upon and removed fractured and displaced pieces which were 
pressing upon the spinal cord. In one instance, — a man whose 
neck was dislocated from being suddenly and forcibly bent down 
by striking against a beam, while passing into a shed on the top 
of a load, — a temporary restoration of innervation was produced 
by making tractions on the head, by which the dislocation was 
reduced. After this, the patient was placed in bed, the head 



FEACTURES. 325 

of it being raised so as to form an inclined plane, witli a strong 
band under his chin. He died, however, with the usual symp- 
toms attending this accident. I do not remember, out of quite 
a large number of these injuries that have fallen under my ob- 
servation, a single case that was benefited by any operative 
procedure. It may possibly be the case, that this has been too 
much neglected of late years from the want of success attending 
the operation. An instance may occur now and then in which 
an operation might result happily. The subject has recently 
excited considerable discussion abroad. 

Of modern appliances for the treatment of fractures, the 
starched bandage of Seutin, or, still better, the dextrine band- 
age of Yelpeau, or the plaster of Paris apparatus, are among 
the most important. There are, in fact, but few fractures 
in which they are not useful at some stage of the treatment. 
In simple fractures, where there is not much injury of the soft 
parts, the bandage may often be applied with advantage im- 
mediately upon the receipt of the injury. In other cases, it 
is necessary to wait until the swelling and inflammation have 
subsided. After union has been effected by the use of other 
appliances, the starched or dextrine bandage is very useful in 
supporting the newly formed callus, and guarding the limb 
against accidents when the patient leaves his bed. 

The application of these bandages is very simple. A dry 
roller of old linen or cotton is first applied, to prevent adhesion 
of the bandage to the skin. A common roller is to be dipped 
in the adhesive liquid, either starch paste or solution of dextrine, 
and is then to be applied to the limb in the ordinary manner, 
taking care to make as few reverses as possible. The dextrine 
solution, which may be made in part with alcohol, dries sooner 
than the starch, and makes a firmer case with the same thick- 
ness of roller. If starch is used, the whole should be strength- 
ened by strips of wet pasteboard, placed on the outside of the 
dry roller, before applying the starched one. 

The plaster apparatus consists, first, of a soft dry roller or a 
thin layer of cotton, applied next to the skin, and covered by 
a second roller, wet with water. The whole bandage is then 
covered with plaster mixed with water to the consistency of 



326 EXTREMITIES. 

thick cream, and confined, if necessary, bj another roller. The 
surface of this may be smoothed with a little more plaster, ap- 
plied with the palm of the hand, and the whole apparatus com- 
pleted by a coat of shellac varnish. This apparatus is easily 
applied, and becomes perfectly solid in the course of the short 
time required for its application. The plaster should not be 
wet until the moment it is to be used ; and, if it still sets too 
quickly, a little alum water may be added. 

The starched bandage may be employed with great benefit in 
those vexatious and often unmanageable injuries, — sprains of 
the ankle ; thus allowing, in some cases, of locomotion at once, 
where a tedious confinement would be necessary under other 
treatment. I have also employed it, for the purpose of com- 
pression, with excellent results, in that very troublesome disease, 
milk abscess. 

Case CLXXXVI. — Fracture of the Malar Bone. — 
1861. A gentleman, walking in State Street, was run against 
by a drunken man, who struck him on the side of the face with 
his head, fracturing and causing the depression of the cheek- 
bone. I saw him immediately after the accident. He said that 
he felt at the time as if he had received a blow from a hammer. 
The malar bone I found broken, and the external portion driven 
in, and firmly fixed. I made an effort to raise it : first, by 
manipulations on the outside ; and afterwards, by passing the 
fingers into the mouth, and forcing them up under the zygo- 
matic arch. Failing in this attempt, a wooden spatula was 
pressed up in the same way, as far as it would go, and an effort 
made to pry the bone into place. The effort was ineffectual, 
and the bone did not seem to yield in the least. I therefore 
advised the application of an evaporating and anodyne lotion 
to the face ; and asked him to report himself to me again in a 
week, as he lived out of town. At the end of that period, 
I found that he had pretty much recovered from the soreness 
produced by the blow : but the depression of the bone still 
continued. 

1 had occasion to see this patient for another accident, nearly 
a year after the date of this injury ; and found the face quite 



FRACTURES. 327 

well, and the irregularity of the bone completely obliterated. 
The patient informed me that he had experienced no interference 
either in the muscular or nervous apparatus of the foce. The 
orbit, in this case, was not apparently implicated in the frac- 
ture. 

In a similar case, which occurred about the same time, the 
accident being produced by a blow of the fist, and in which 
I made the same efforts to replace the bone, but without effect, 
the ultimate result was the same. So far as I know, this is the 
usual history of these cases ; attempts at replacement being in- 
effectual, and the results generally favorable. 

Case CLXXXYII. — Fracture and Depression of the An- 
terior Wall of the Superior Maxillary Bone ^ with the Malar 
Bone. — The following is the only instance I have seen of this 
uncommon accident. A o-entleman comino^ out from bathino; 
slipped suddenly on the seaweed ; and, before he could protect 
himself with his hands, fell, a projecting rock striking him under 
the eye, and depressing the malar and the upper part of the 
maxillary bone at the margin of the orbit. The suffering at first 
was intense, and, as it subsided, left the jaw and the teeth of 
that side in a benumbed state. The depressed portion was fixed, 
and of course could not have been elevated except by means of 
a trephine. The patient recovered well, though slowly, and 
without perceptible deformity ; the nerves of the teeth being, 
for a long time, in an insensible state. 

Case CLXXXYIII. — Fracture of both Upper Maxillary 
Bones, and Separation from Bones of Face. — An old lady, 
aged 70, descending some steep steps into a cellar, fell, and 
received the full force of the fall on the face. I saw her shortly 
afterwards, in a state of imminent suffocation. The superior 
maxillary bones were detached, and had been driven back into 
the throat ; the whole face, in fact, appearing as if forced in- 
wards. Both from the blood, and froai the obstruction caused 
by the pressure of the bones in the fauces, breathing was very 
laborious, and was becoming less and less possible when I saw 
her. 



328 EXTREMITIES. 

The bones were drawn forwards, and easily restored to their 
places : recurrence of the displacement was prevented by a 
bandage, securing the upper and lower jaws together, liquid 
food being given between the teeth. 

Great swelling and ecchymosis of the face followed ; but the 
fractured parts united well with the bones from which they had 
been separated, and the woman fully recovered. 

I have twice met with this accident, both cases occurring in a 
similar way. 

Case CLXXXIX. — Fracture of Epiphysis of Head of 
Humerus. — In June, 1865, a girl, 16 years of age, was 
brought to me, who had fallen down stairs the night before, and 
who said she had wrenched her shoulder. She could not raise 
the arm without great difficulty, and there was much tenderness 
over the deltoid muscle. The shape of the shoulder was 
natural, the head of the bone being evidently in its place. On 
seizing this with one hand, and rotating the humerus with 
the other, the head of the bone moved with the shaft, and no 
crepitus was felt. 

She was examined by a number of surgeons, and some 
thought it to be a rupture of muscular fibres ; others, simply a 
strain. 

In the course of the investigation, the arm was raised up to 
a right angle, and carried somewhat backwards, when, on rota- 
tion, an occasional crepitus could be distinguished. 

This examination being borne with difficulty, it was deter- 
mined to etherize her, which her parents would not consent to 
till the following day. The next day she was placed fully under 
ether ; and, the muscles being relaxed, the head of the bone was 
projected forwards, as had been done the day before. The epi- 
physis could now be seized with the fingers ; and, the shaft 
being rotated, it moved freely within the capsule, independently 
of the rest of the bone. 

A pad was placed in the axilla, and a shoulder-splint ap- 
plied : the arm was confined to the side, and supported in a 
sling. She came to the Hospital, from time to time, for advice 
and dressing. The bone united very rapidly, and, in the course 
of a few weeks, the motions of the arm were entirely restored. 



FEACTURES. 329 

This case is quite interesting from its rarity, also from the 
fact of the obscurity of the diagnosis ; no crepitus being felt 
while the arm was applied to the side and the head of the bone 
drawn tightly up into the socket by the irritated muscles. 
These, beino- relaxed bv ether, disclosed the nature of the acci- 
dent. 

Case CXC. — Ununited Fracture of the Humerus, Se- 
ton. Cure. — A man, 55 years of age, was brought to me by 
his physician, in the latter part of May, 1859, with an ununited 
fracture, situated about the middle of the right humerus. The 
fracture had been caused six months before by a cart running 
over the arm. It had been treated in the usual way, by splints ; 
but the ends of the bone had failed to unite, and the limb in 
consequence was useless : the fore-arm was flexed on the arm, 
and the elbow was more or less stiff. There was complete flexi- 
bility of the arm at the seat of fracture, so that I had great 
doubt as to the success of any operation. 

This ease being an appropriate one, I determined to try the 
seton. The fracture was oblique ; the lower fragment lying 
directly anterior, the upper posterior. An instrument traversing 
the fissure, between the two fractured ends, was liable therefore 
to strike upon the bundle of vessels and nerves which lay directly 
against the internal line of fracture, rendering some caution 
necessary in the management of the operation, wdiich was done 
as follows : — 

A long incision, corresponding to the line of fracture, was 
made directly behind it ; and, by dissection, muscular fibre 
was exposed. This being satisfactorily ascertained by the point 
of the finger, and the vessels pulled forward out of the way, 
the seton-needle, threaded with a skein of silk, was forced be- 
tween the fractured ends of the bone, and through the muscle 
and skin of the opposite side. A free rush of arterial blood 
followed the passage of the instrument ; indicating that some 
arterial branch, of considerable size, had been wounded. A 
folded towel was now placed over the wound ; and firm com- 
pression made, by means of a roller, from the hand to the 

42 



330 [exteemities. 

shoulder. The patient was placed on his back in bed ; and 
the arm elevated on a pillow in the bent position. 

He passed a pretty comfortable night, and had no bleeding. 
The bandage was removed ; but the cloth, which had become 
saturated with blood and dried, thus forming a clasp round the 
limb, was not interfered with, as it was found the circulation in 
the main vessel was well performed. 

All the dressings were removed on the fourth day : the arm 
and fore-arm were placed in a gutta-percha splint, well moulded 
to fit the inside. 

No constitutional irritation of any consequence followed the 
operation, or any purulent deposit, such as I have frequently 
witnessed. On July 20th, after the seton had been in place 
thirty days, there being some indication of this occurrence, the 
seton was withdrawn. The wounds at once rapidly healed ; 
and on the 24th, an examination being made, the bones were 
found firmly united, and he was allowed to lay aside his splints, 
and o-o about with a slino^. 

Shortly after this, an attempt having been made to overcome 
the stiffness of the elbow, which had remained firmly flexed 
since the treatment for the accident, the mobility at the seat of 
fracture was again felt. The splints were therefore re-applied, 
when union again became firm ; and it was determined to make 
no farther attempts until the lapse of time should have insured 
the bony consolidation of the humerus. This point is worthy of 
notice, as I have twice seen a fresh union in the femur destroyed 
by attempts made to overcome the stifihess of the knee-joint. 

Case CXCI. — Fracture of the Lower End of the Ra- 
dius, ivith other Fractures. Death, Autopsy. — 1851. A 
man, 30 years old, was brought into the Hospital, having 
fallen a distance of forty feet through a scuttle to the floor. 
The following is from the Hospital records : — 

"At entrance, at 6, p.m., there is fracture of the right ra- 
dius, apparently just above the joint. There is great deformity, 
simulating dislocation of the wrist backwards. Crepitus dis- 
tinct. 

"The right leg is shortened, by measurement, one and a 



FRACTURES. 331 

quarter inches. It is everted, with edge of foot lying flat upon 
the table. There is distinct crepitus at or near the cervix femo- 
ris. When pressing the two iliac crests, they yield sensibly, 
and give a feeling of indistinct crepitus." He died at 10, p.m. 

At the autopsy, the following were some of the pathological 
appearances exhibited : The right radius was fractured trans- 
versely, half an inch above the joint, with a comminuted frac- 
ture extending into the joint. The internal lateral ligament was 
torn away from its attachments to the ulna, carrying a bit of 
the bone with it. 

The right femur was the seat of a comminuted fracture 
through the trochanter ; and a longitudinal fracture of the shaft 
of the bone extended from its cervix downwards for four inches. 
Keither of these fractures communicated with the capsular 
ligament. ;' 

The right sacro-iliac synchondrosis was torn asunder, and the 
bones formino- it fractured. The ramus of the ischium and 

o 

pubes was fractured. The lower half of the sacrum and os 
coccvs^is were comminuted. 

Remarks. — The fracture of the lower extremity of the ra- 
dius is an accident of peculiar interest to surgeons from the 
liability to deformity, in spite of the best-directed treatment. 
The various apparatus invented by distinguished surgeons, with 
the object of preventing this deformity, show the importance 
attached to it. From simply regarding the external appearances 
presented by this fracture, it was formerly supposed that the 
bones yielded in an oblique direction : but observation of patho- 
logical specimens has shown that it is, on the contrary, almost 
always transverse ; the peculiar deformity arising not so much 
from the overlapping of the fragments, as from the direction of 
the displacement by muscular action. Dr. Smith, of Dublin, 
in twenty specimens which he examined, found the fracture to 
have a transverse direction in eighteen. In the present instance, 
it was transverse. 

Case CXCII. — Fracture of Ann, with Subsequent De- 
formity. Restoration by Force after Six Months. — The 
folio win o- is an instance of the leno'th of time at which an an- 



332 EXTREMITIES. 

gular deformity from fracture may be remedied in a young 
person. The patient was partly under my charge, and partly 
under that of one of my colleagues. A boy, 16 years of age, 
entered the Hospital on the 9th June, 1863, who, six months 
before, had fractured both bones of the fore-arm, near the 
middle, by a fall. Splints were applied soon after the accident ; 
and, when they were removed, at the end of five weeks, the 
fracture had united, but the arm was crooked. This deform- 
ity had increased, and the usefulness of the arm was impaired 
by it. 

There was a large callus at the point of fracture. The 
deformity was of two kinds ; consisting of a partial fixed pro- 
nation of the arm below the fracture, and an angular curvature 
in the. sense of flexion. Straight splints, well padded, were 
applied on the flexor and extensor surfaces of the arm, and 
firmly secured by bandages. 

The use of these splints, variously applied, was continued 
for one month, at the end of which time the arm was a very 
little straighter. The patient, being dissatisfied with the slow 
progress of the cure, although it was gradually eflecting the 
object, on the 10th of July was etherized, and the arm for- 
cibly straightened. The ordinary spoon-shaped splint, with a 
roller bandage, was then applied. In a little more than a month 
after the operation, the shape of the arm was found to be nor- 
mal, and the fracture quite firm. He was discharged from the 
Hospital, with orders to continue the use of the splints for some 
time. On the 12th of September, the fractured arm was as 
strong as the other, and perfectly straight. 

Fractures of the Patella. — For many years, I used 
the ordinary methods proposed by Sir Astley Cooper, Boyer, 
and others, for the treatment of fractures of the patella, such as 
mechanical contrivances made of wood, or powerful straps placed 
above and below the fractured ends, which were approximated 
by screws, straps, strings, or bandages; and I was always 
struck by the great pain and swelling produced by their ap- 
plication. They seemed to act principally on the skin, even 
when applied in a moderate manner, so as not to produce in- 



FRACTURES OF PATELLA. 333 

jury of the integument. If they had any mode of acting on 
the .broken bones, it was to depress tlieir edges, and throw the 
fractured faces forwards. This idea has since been verified by 
observing one or two specimens in the Museum of the Boston 
Society for Medical Improvement, collected by the distinguished 
pathologist, Dr. J. B. S. Jackson. Seeing the results by the 
old method, it occurred to me to trust almost entirely to posi- 
tion ; the only accessory means employed being a broad strip of 
adhesive plaster, with a hole in the centre large enough to 
receive the patella, which is applied after the inflammatory symp- 
toms have subsided. 

My plan of treatment has been this : Immediately after the 
accident, the patient is placed on a bed, his leg raised on an 
inclined plane, to form an angle of about 45° with his body. 
A cradle is now placed over the foot, to prevent the contact of the 
bed-clothes ; and compresses are placed over the injured part, wet 
with some cooling lotion. In case of any great inflammatory 
action, leeches are applied ; but this has very rarely been neces- 
sary. At a later period, when pressure can be borne without 
any uneasiness, a strip of plaster, arranged as above, after being 
well warmed, is nicely adjusted on the thigh by one end. The 
upper fragment of the patella is then engaged in the opening, 
slowly dragged down, and the other end of the plaster is then 
made to adhere to the front part of the leg. Circular straps 
may be used if necessary. The comfort of the patient is im- 
measurably great, compared with the tormenting applications 
formerly used ; and the success of the treatment is quite as 
good. Still, it is somewhat doubtful, whether, in most cases, 
the fracture would not do quite as well, placed in a ham splint, 
gently supported by bandages without elevation. In fact, I 
have tried this plan a number of times, and with good suc- 
cess. 

The late Dr. A. A. Gould, a number of years since, at the 
time when I was first trying the method by position, reported 
to the Society for Medical Improvement the case of a patient 
whom he had treated by keeping the limb suspended, at an 
angle with tlie body, from the bedpost, without bandages, which 
w^as followed with gratifying success. 



334 EXTREMITIES. 

During the year 1858, having had a number of cases under 
my care, out of the Hospital, in which I was able to follow 
their progress, I was somewhat struck at the various periods at 
which patients recovered the use of the limb, after the accident; 
and found it much longer, in most cases, than was generally 
supposed. In order to obtain information on the subject, I pro- 
posed the question at one of the meetings of the Society above 
mentioned, and found from the experience of other medical men, 
that some of their patients had recovered in about three months ; 
others required one or two years before the stiffness was lost, 
and power of flexion restored : one case was mentioned in which 
the power of the limb never returned, and the patient was 
obliged to go about on crutches. The recovery of the free 
motion of the limb did not correspond in these cases with the 
completeness of the union of the separated fragments ; some of 
them doing remarkably well with quite a long ligamentous 
union. 

I propose to illustrate the above observations by a number of 
cases which have come under my care, treated by various 
methods. 

. Case CXCIII. — Fracture of Patella. — A young lady, 
about 25 years of age, while bathing in the sea, in attempting 
to lift up a child, felt a sudden snap about the knee, and imme- 
diately lost the power of supporting herself. She was assisted 
out of the water, and taken home ; when the left patella was 
found to have been broken, and the fragments separated from 
one to two inches. I saw her a few hours afterwards. She 
was directed to be placed on her back, the leg and thigh to be 
slightly elevated, and a compress, wet with spirit and water, to 
be applied over the joint. Being somewhat delicate and dys- 
peptic, her food was ordered to be carefully regulated; and, to 
partially obviate the ill effects of confinement, she was bathed 
over once a day with warm salt water, followed by moderate dry 
friction. 

After the first or second day, finding no undue inflammatory 
action about the joint, and even fearing a want of action j the 
wet applications were discontinued, and the limb placed in a 
hollow splint, more fully to prevent flexion. 



FRACTURES OF PATELLA. 335 

This patient was confined about six weeks before the union 
seemed to be sufficiently firm to allow her to get up. She was 
then permitted to rise ; a small splint of gutta-percha being- 
placed at the back of the joint to give it support. This was 
removed daily, and gentle flexion given to it. Finally, at the 
end of nearly three months, she was able to bear her weight on 
the limb, and go out supported by a cane and crutch. 

About eighteen months after the accident, although every 
means such as frictions, lubricating the part with ointments, and 
as much flexion as could be made without danger of breaking 
the intervening ligamentous union, had been applied, she was 
still unable to bend her leg farther than at a right angle. The 
separation of the fragments was from a quarter to half an inch. 
Once during this period, apparently from a peculiar state of the 
constitution, she had an attack of synovitis in that knee ; the 
other knee-joint being, at the same time, a little tender. 

This accident, it should be observed, occurred in a lady of 
very delicate constitution. The limb, from the first, was un- 
restrained by bandages ; pretty early flexion was used ; and yet, 
at the end of a year and a half, the limb could not be complete- 
ly bent. The treatment above described, of frictions and gentle 
flexion, was continued, and, two years after the injury was 
received, she entirely recovered the use of her limb. 

Case CXCIV. — Fracture of Patella. — At the same time 
that I had the preceding case under my care, a young woman, 
about 25 years old, of powerful make, acting as servant in a 
friend's family, was brought into the Hospital, and came under 
my care. Having fallen the day before, while descending the 
stairs, she struck her knee, and produced a fracture of the pa- 
tella. She w^as placed on a fracture-bed, the lower portion 
of which supported the injured limb, elevated at an angle of 
about 30°. Her head and shoulders were also slightly elevated 
in the same way. Cooling applications were placed over the 
fragments, which were left entirely unrestrained by any bandage. 
She was confined by the accident about two months ; and, when 
she left the Hospital, the fractured ends were separated about 
half an inch. 



336 EXTEEMITIES. 

I saw this patient a number of times afterwards. At the end 
of six months from the accident, although the union was per- 
fectly good, and all the appropriate means had been used to gain 
the use of the joint, she still required a very firm-laced bandage, 
supported laterally ; was unable to bend the limb so as to pick 
up any thing from the floor, and was obliged to walk with the 
support of a cane. 

Case CXCV. — Fracture of Right Patella ; Subsequent 
Fracture of Left. — A man, aged 33, a mechanic, fell, Jan. 7, 
1857, on the ice, and fractured his right patella transversely ; 
the fragments being separated about an inch. He suffered but 
little pain from the injury when brought into the Hospital. He 
was put upon the inclined fracture-bed, and treated at first in 
the same manner as the preceding cases ; strips of adhesive plas- 
ter beins: used after the inflammation had subsided. He was 
discharged well, on March 2 2d, the fragments being separated 
about a third of an inch. 

On Nov. 22, 1858, he was again brought into the Hospital, 
having had his left knee struck by an iron bar, which produced 
a transverse fracture of the patella ; the fragments being separ- 
ated about three-quarters of an inch. His leg was placed on a 
Goodwin's splint, and much elevated. 

On Feb. 1, 1859, there was good ligamentous union, with 
separation of about one-third of an inch ; and he was allowed to 
get up, the limb being supported by a bandage. On February 
20th, some slight separation of the fragments was found to have 
taken place. On March 1st, no further separation had occurred, 
the space between the fragments being about half an inch. 

An examination of the other limb of this patient, the patella 
of which had been broken nearly two years before, disclosed the 
fact, that the fragments had been separated in an extraordinary 
manner at least three or four inches. He said that, on leaving 
the Hospital, he had used the limb without any precautions. In 
consequence, the fragments gradually became separated, and he 
finally lost the power, almost entirely, of extending the limb ; 
so that, in walking, it was necessary to lift the leg from the 
ground, and give it a jerk forwards by a slightly lateral motion. 



FRACTURES OF PATELLA. 837 

Moreover, if extreme care was not taken in managing the joint, 
by walking with the head and shouklers bent forwards so as to 
throw the centre of gravity rather in front of the knee, the 
joint woukl give way, and throw him upon the ground. 

Case CXCVI. — March, 1859. A man, 30 years of age, 
consuked me for an injury of the left patella, which, he said, 
had been fractured twelve years before ; and for which he had 
been treated at the Hospital in Dublin, and had a good use of 
the limb since. The day before I saw him, he had fallen, and 
felt something give way about the knee ; and supposed he had 
met with the same accident a second time. 

I found what appeared to be at first a vertical fracture of the 
patella. But, on more careful scrutiny, what seemed to be 
a fissure in the bone proved to be made by a projection of the 
outer condyle of the femur in apposition with a very small pa- 
tella of less than half the natural size. 

On examining the right limb, in order to make a comparison, 
I found not the slightest traces of any patella. The joint, in 
fact, could be fully explored ; and seemed only to be covered by 
skin, fascia, and capsular ligament. The patient said that the 
motions of the joint were perfectly good ; and that the only 
explanation he could give was, that, when a child, he had an ex- 
tensive suppurating sore over the knee-joint, following small-pox. 

For the present injury, attributing it to the rupture of adhe- 
sions, I advised him not to confine himself, but to have a knee- 
cap well adjusted, to afford the limb support. He presented 
himself, some days afterwards, with this appliance, walking with 
ease, and only embarrassed on mounting a staircase. 

Case QX.QYll. — Fracture of Patella. —March 16, 1859. 
A man, aged 40. This patient was in the Massachusetts Gen- 
eral Hospital four years before, with fracture of both thighs, 
from which accident he completely recovered. To-day, he fell, 
downstairs, and struck directly on the right knee. The patella 
was found to be broken into three pieces, with but little sep- 
aration of the fragments however. He was immediately placed 
in bed, with his limb resting on an inclined plane. 

43 



338 EXTREMITIES. 

During tlie treatment of the case, there was but little pain, 
although considerable effusion took place. The recovery was 
excellent. 

Case CXCVIII. — Fracture of Patella. — March 17, 
1859. The patient, a man of 60 years, fell from a hay-mow, 
and struck his left knee on the barn floor. There was a fracture 
of the patella, with very great effusion. 

He was placed in bed, with his leg resting on an inclined 
plane. The case went on to a favorable termination. 

Case CXCIX. — Rupture of the Tendon of the Quad^n- 
ceps Extensor Fenioris JSIuscle^ just at its Insertion i7ito the 
JPatella. — In connection with fracture of the patella, the fol- 
lowing case may be given. It was treated by position about 
the same time that I began that treatment of fractures of the 
patella, and is of very rare occurrence. 

A man about 60 years old, subject to rheumatism, while 
sweeping the pavement on a frozen surface, slipped ; and, in 
endeavoring to recover himself, felt something give way about 
the knee-joint, and at once fell to the ground. When brought 
into the Hospital, it was found that a wide gap existed between 
the quadriceps tendon and the patella, the skin being depressed 
at that point, so that the knee-joint could be completely explored 
by the finger. The patient was placed on his back ; and the leg 
elevated at an angle of about 45° from the bed, and supported on 
an inclined plane, and cooling lotions applied to it. Much swell- 
ing and effusion into the joint followed ; and, as no advantage 
could be perceived from the use of bandages, they were laid 
aside. Union gradually took place between the tendon and 
patella; and, after a treatment of a number of months, he 
finally recovered a good use of the limb. 

I have seen three or four instances of persons who, having 
received a blow just below the patella, failed to recover the use 
of the leg. On a very careful inspection, a transverse crack, or 
rupture, was distinguished, partially dividing the fibres of the 
ligamentum patellae. There was no other appearance or symp- 
tom to explain the loss of power over the leg. These patients 



FRACTURES. 339 

did well after a confinement of from three to six months in a 
ham splint. 

Case CC. — Fracture of the Pelvis, with Rupture of 
Bladder. — A man, 30 years old, died on his way to the Hos- 
pital, a bank of earth having fallen on him an hour before. 
The following were the appearances presented by the body : A 
fulness was observed in the right iliac region. The perinagum 
was somewhat fuller than natural to the right of the median line. 
The left side of the pelvis appeared drawn up, so that its spi- 
nous process was above the level of the right spinous process. 
The right lower extremity was, by measurement, one -half an 
inch longer than the left. On examination of the pelvis, a 
fracture was detected near the symphysis pubis ; also one through 
the left sacro-iliac synchondrosis. By rotating the left lower 
extremity, the left ilium was freely movable, with some crepitus 
attendino^ the motion. Powerful flexion of the rioht lower ex- 
tremity produced an indistinct crepitus in the joint. 

A catheter was passed, with some difficulty, through the 
urethra ; and its point could at once be distinguished in the cavi- 
ty of the abdomen. 

Permission being obtained, the autopsy was made five hours 
after death, by Dr. F. J. Bumstead, then house-surgeon at the 
Hospital, who drew up the following account of it : — 

" On cutting into the peritoneal cavity, it is found to be entirely 
filled with blood. Its posterior wall is covered with a dark-colored 
ecchymosis, and is raised by a large effusion beneath. A small her- 
nia of the tissues, external to the peritoneum, about the size of the 
little finger, protrudes through the membrane, back of the right os 
pubis. The confused state of the parts beneath the peritoneum ren- 
ders a minute examination impossible. The blood has undermined 
the peritoneal cavity, and infiltrated the iliacus and psoas muscles. 

" The bladder is ruptured to the extent of an inch above the tri- 
angular ligament, and posterior to the symphysis pubis. The diagno- 
sis of fracture through the symphysis, and through the left sacro-iliac 
synchondrosis is found to have been correct. The fragments of the 
latter are separated to the width of a finger. In addition, the right 
acetabulum is crossed by several fractures, which extend through the 
ischium and ilium, entirely isolatiug several pieces of bone. From 



340 EXTREMITIES. 

the fundus of the acetabulum, a triangular piece of bone has been 
draAvn inwards, and the corresponding surface of the head of the 
femur is crushed to the depth of one or two lines. Ligamentum teres 
not injured." 

Case CCI. — Fracture of the Nech of the Thigh-bone 
in a Gentleman Ninety Years of Age. Recovery. — The 
gentleman who was the subject of this case was a person of the 
most energetic character ; his health had never been abused by 
any excess, and he had always lived with the utmost sim- 
plicity. His mind was of great activity, and he had occu- 
pied many positions of distinction and trust in the State and 
country. 

His case was particularly interesting to myself from his 
having been brought into professional relations with five mem- 
bers of my family, during a period of ninety years. 

The fracture was produced by a fall from his 'chair, Dec. 11, 
1861. He was unable to rise, and was placed upon a mat- 
tress, on the floor, in which position I saw him half an hour 
afterward. 

The limbs were found of an equal length, and there was no 
eversion of the foot. On gentle rotation of the limb, with a 
finger in the groin, a distinct crepitus w^as observed. The tro- 
chanter rotated with the shaft of the bone. 

About six hours after the accident, a fracture-bed, with a 
triple inclined plane, having been obtained, he was placed upon 
it,. Before this was done, it was found that the foot was everted, 
and the limb shortened between one and two inches. After 
being kept in this position about tw^o wrecks, he began to be un- 
easy ; complained of some soreness of the back, in spite of 
every precaution which had been taken, and spasmodic actions 
in the extremities manifested themselves. He was then moved 
to a new bed, which I had contrived for the purpose, consisting 
of a triple inclined plane, placed on a second plane, with which, 
by a rachet movement, the patient could be brought up into a 
sitting posture without disturbing the fracture, and the pressure 
brought more on the tuberosity of the ischium and thighs. IJy 
the use of this bed, his condition was much improved ; and, in 



FRACTUKES. 341 

the course of the winter, he recovered the use of the limb, with 
some shortenino- and eversion. 

During the treatment, he once or twice fell into a somno- 
lent state, in which he remained two or three days, the pulse 
becoming extremely slow ; and fears were entertained that life 
would cease in one of these attacks. On coming out of them, 
however, his vitaHty was gradually restored. 

He lived about a year afterwards : and finally died quietly 
without any marked symptoms of disease. 

Case CCII. — Fracture of the Upper Part of the Shaft 
and JSfech of the Os Femoris, in a Lady, aged Eighty-six. 
No Crepitus. Death in one Weeh. Autopsy. — 1854, Jan. 9. 
This patient, about a week before her death, fell in her room, 
striking on the trochanter of the right thigh-bone. She was 
unable to rise, and was taken up and placed in bed. On ex- 
amination, it was found tliat the right lower extremity was 
shortened about an inch, and the foot everted. The thigh was 
much swollen. Xo crepitus could be discovered on any motion 
given to the limb. She was placed on her back ; the limb 
supported on a double inclined plane, made of pillows. She 
complained of but little pain in the injured part. For a few 
days she did well. The bowels then became constipated, the 
pulse failed gradually, and she died on the sixth day from the 
reception of the injury, apparently from the shock to a system 
reduced by age. 

On a post-mortem examination, before the injured parts were 
exposed, an attempt was made to obtain crepitus ; but none was 
produced by the ordinary motions of the limb. By extreme 
flexion, however, using at the same time powerful rotation, a 
crepitus could be distinguished. On making an incision over the 
trochanter down the thigh, the fat arid muscles Avere found filled 
Avith extravasated blood. There Avas a comminuted fracture of 
the shaft of the bone, just beloAV the trochanter ; and another 
fracture extending upAvards from this as far as the edge of the 
socket, separating the neck of the bone from the trochanter. 
But little blood Avas eflused into the cavity of the joint. 

This case is Avorthy of remark as shoAving hoAv extensive a 



342 EXTREMITIES. 

fracture may be ; and yet, from the extravasation of blood, and 
from other causes, one of the principal diagnostic signs of frac- 
ture, crepitus, not be obtained. 

Case CCIII. — Fracture of the Nech of Thigh-bone^ in an 
Old Lady One Hundred Years and Six Months old. In- 
version of Foot. Death three W^eehs afterwards. No 
Union of Fracture. Solid Collection in Rectum. — The 
old lady who was the subject of this notice died January, 
1837, after a long life of uninterrupted good health, aged 100 
years and 6 months ; her death being finally accelerated by a 
fracture of the hip, which occurred a few weeks previously. 
For a year, she had been subject to some aberration of mind, 
which required her to be somewhat restrained in her motions ; 
and, as she had a constant desire to leave the house, her clothes 
were taken from her, and she was confined as much as possible 
to the bed. Three weeks before her death, while left by her- 
self, she was heard by the persons in the room below, to get out 
of her bed ; and, while walking across the room, to fall heavily 
on the floor. Upon going into her chamber, she was found pros- 
trate, and unable to rise. She was immediately carried to her 
bed, her medical attendant called, and, an examination being 
made, it was discovered that a fracture had taken place through 
the neck of the thigh-bone. 

There was but little displacement of the fi:-actured parts, the 
limb being a little shortened and the foot inverted ; and it was 
determined, therefore, that the application of any apparatus 
for confining the limb would be unnecessary, position only being 
relied upon for the union of the bone. She was directed to lie 
upon her back ; and a pillow was placed under the thigh, so as 
to keep it slightly flexed on the pelvis. She died about three 
weeks after the accident ; her death taking place without suffer- 
ing, and apparently occasioned by the combined eflects of the 
accident, and the confined position necessarily attendant on it. 
It may be well to state that the senses of the old lady remained 
perfect to the last. Her hearing was good, and she was able 
to read the smallest print without the use of glasses. 

The body was examined twelve hours after death, and pre- 



FRACTUEES. 343 

sented the following appearances : Stature small, about five 
feet ; very little emaciation. On the lower part of the sacrum 
was a gangrenous spot, two inches in diameter, occasioned by 
the long pressure on that part from her confined position. The 
left lower extremity was shortened perhaps a quarter of an 
inch, and the toes slightly turned inwards. Upon opening the 
head, about a gill of serum escaped from the cavity of the dura 
mater. This membrane was strongly adherent throughout to 
the cranium, requiring the use of much force to separate it from 
its attachments. The superficial vessels of the brain were much 
distended with blood ; its substance of good consistence, offering 
otherwise nothing remarkable. All the sutures of the cranium 
were completely ossified. The cartilages of the ribs were not 
ossified, as is usually the case in old persons, and were easily 
cut throusfh with the knife. 

o 

The lungs were of a dark-blue color on the left side ; at 
the summit, strongly adherent to the ribs ; and, at this point, 
a conglomeration of small semi-transparent granulations were 
found embedded in the substance of the healthy lung. These 
OTanulations were scattered throuohout the luno^ ; but at no 
point was there any appearance of cicatrices or tubercles in a 
softened state. The edges of the lower lobe of the right lung 
presented the most marked appearance of emphysema. The 
heart was small ; its cavities filled with black, uncoagulated 
blood. The free edges of the valves of the aorta were not 
ossified : at their bases, however, and at that part of the 
aorta opposed to their edges, were two distinct osseous rings. 
Patches of osseous deposits, some of them an inch in diameter, 
were scattered at intervals throughout the whole course of the 
aorta. The liver, kidneys, and spleen were perfectly healthy, 
and of the natural color and consistence. The stomach was 
remarkably small, — its calibre about the same as that of the 
duodenum, from which externally it was difficult to distinguish 
it, — and presented much the appearances I had observed about 
a year before in the stomach of an old lady who had destroyed 
herself by starvation, with this exception, that, in the latter 
case, the mucous coat was much more corrugated. The intes- 
tines were generally of small size ; at some points, in the large 



344 EXTKEMITIES. 

intestines, not being more than half an inch in diameter. At 
the rectum, however, a very remarkable phenomenon presented 
itself. 

The intestine was here dilated into a large pouch, completely 
filled by a ball of hardened fecal matter, which, occupying the 
whole cavity of the pelvis, forced the bladder completely out of 
its natural situation ; below, this mass was found pressing 
down on the perineum, and slightly dilating the anus. From 
all appearances, this ball must have been for a long period 
in the situation in which it was discovered, as she had com- 
plained of no suffering, and the bowels had been perfectly 
regular up to the day of her death. The matter evacuated of 
course passed down at the sides of the obstruction. 

The bladder was large ; its mucous coat somewhat reddened, 
and rather softer than natural. The uterus was about the 
size of a hazel-nut ; and, on cutting into it, a small quantity of 
pus, apparently of recent formation, escaped from its cavity. 
Nothing remarkable was observed about the ovaries, either as to 
size or consistence. Upon examination of the hip, it was found 
that a fracture had taken place at that part in a very remark- 
able manner. In the first place ^ a fracture extended from the 
trochanter transversely through the neck of the os femoris ; 
in the second place, the trochanter major was completely separ- 
ated from the body of the bone. The displacement of the frac- 
tured portions, however, was very slight ; they being interlocked 
by irregular serrations, although freely movable on each other. 
The trochanter minor was nearly split through. 'There appeared 
to be no attempt at union. 

The remarkable features of this case are : First, the inver- 
sion of the foot; second, the want of ossification about the ribs, 
which would naturally be expected in a person of such advanced 
age ; third, the small size of the stomach ; fourth, the great 
mass of hardened feces in the rectum, allowing, nevertheless, 
the regular passage of matter at the sides, so that, previous to 
death, nothing of the kind was suspected. A case in which a 
similar collection took place is given in one of the numbers of 
the "London Medical Gazette." The patient was a lady sev- 
enty years of age, who had suffered for some time with most 



FRACTURES. 345 

excruciating pains in the lower part of the rectum. These 
pains were periodical, and similar in their character to the 
bearing-down pains of labor. An examination being finally 
made, it was found tliat a large mass of hardened feces, of the 
size of the head of a fall-grown foetus, was pressing down upon 
the perinaeum ; the anus being distended to the size of a crown- 
piece. This mass was broken down with the handle of a spoon, 
and the sufferings of the patient immediately relieved on the 
removal of the obstruction. Nothing of the kind had been 
suspected, as the patient had always enjoyed a regular state 
of bowels. I have met with a similar instance in the case of an 
insane person, also in the case of a fracture of the neck of the 
thigh-bone In an old gentleman, hereafter to be related ; in both 
instances requiring a prolonged operation with the scoop which 
accompanies lithotomy instruments, for removal. 

The inversion was caused by the serrations becoming inter- 
locked ; the blow breaking the bone, and at the same time giv- 
ing it a twist inwards, in which position it was retained, as above 
described. In conclusion, it may be observed that the bones 
were not more brittle than is ordinarily found in persons of 
forty or fifty years of age. 

I have in my possession a specimen of intra-capsular frac- 
ture of the neck of the femur, with inversion of the foot, oc- 
curring in a lady ninety-three years old. It was presented to 
me by the venerable Dr. Alden, of Randolph, under whose care 
the patient was. 

Case CCIV. — Intra-capsular Fracture of the Cervix 
Femoris. Death from Intestinal Strangulation, — Dec. 1850. 
A gentleman, 83 years of age, fell upon a carpeted floor, striking 
the right trochanter. When taken up, he was found to be suf- 
fering severe pain : the foot was everted, and the limb shortened 
half an inch. He was placed on a triple inclined plane fracture- 
bed ; the foot being supported by means of pillows, and pro- 
tected by a cradle. At the end of seven weeks, he was able to 
move the leg without pain, and the foot was not disposed 
to evert. 

On Jan. 30, 1851, he was seized with a pain in the eplgas- 

44 



346 EXTREMITIES. 

trium, accompanied by vomiting. The pain was relieved on the 
31st ; but the vomiting continued, at intervals, until his death, 
which occurred on Feb. 4th. During this period, there was 
no pain on pressure over any part of the abdomen, and no 
tumor was perceived. One evacuation, of a solid consistence, 
took place from the bowels, by means of an enema, on the 2d 
of February. The urine was suppressed for twenty-four hours ; 
afterwards, it was passed naturally. 

On examination after death, it was discovered that about 
eighteen inches of the ileum, in the neighborhood of the coecum, 
had passed through an aperture in the circumference of the 
omentum, apparently made by an old adhesion : all this por- 
tion of the intestine was black, but not in a state of gangrene, 
the strangulation being partial. The capsule of the hip-joint 
being opened, there issued a small quantity of dark-colored 
blood. A fracture was at once seen, passing transversely 
through the neck of the bone. The parts, however, were firm- 
ly interlocked ; and it was only after efforts of forcible rotation 
were made, that they partially separated. A portion of the 
periosteum, at the back part of the cervix, remained entire. 
The effects of the fracture were to produce a slight shortening 
of the neck of the bone, by the fragments being driven, as it 
were, one into another ; and an additional shortness of the limb, 
from the partial dra wing-up of the shaft of the bone by muscu- 
lar contraction. 

In the following case, the patient walked some distance after 
a complete fracture of the neck of the thigh-bone within the 
capsular ligament. He never would submit to any systematic 
treatment, not thinking his hip broken, and never recovered the 
use of the limb. He died two years and a half afterwards, with 
a cerebral attack, attendant on a suppression of urine. The 
case has been fully described by Dr. J. C. Warren, under 
whose care he at first was, in the American edition of Cooper 
on " Dislocations and Fractures," and is accompanied with a 
woodcut. For the last year of his life, he was under my care. 

Case CCV. — Fracture of the Cervix of the Os Femoris^ 
within the G^i/psular Ligament ; ivith a partly Osseous^ and 
'partly Cartilaginous Union. Locomotion after Lnjury. — 



FKACTURES. 347 

" The patient was a gentleman of education and talents. He 
studied medicine in the early part of his life, but afterwards left 
it for another profession. A constitution naturally weak, and 
impaired by disease, gradually gave way ; so that, at sixty, he 
had the appearance of decrepitude. He however continued to 
go out and attend to some business, till he reached the age of 
seventy, when he met with a peculiar accident, 

"Being a member of the Massachusetts Senate, he was in the 
act of ascending the steps of the State House, for the purpose 
of taking his usual seat with that body, when he fell, and struck 
on the left trochanter. On arising, he found himself quite 
lame, though able to stand and walk. In this condition he 
went up the steps, and entered the House, where he remained 
an hour and a half, and made two or three speeches ; during the 
last of which he was oblio-ed to sit down, leavins^ it unfinished. 
A carriage being called for, he was sent home, and I was re- 
quested to visit him. 

" I found him in his parlor, sitting on a sofa, with his feet on 
the floor, as if nothing had happened. He described the acci- 
dent, and I directly came to the conclusion that he must have 
fractured the neck of the thigh-bone. 

"On examining the injured limb, I found no appearance of 
distortion, deformity, or any other change. It was of exactly 
the same length as before the accident (having been rendered 
half an inch shorter than the other by an injury of the knee, 
received at an early period of life). It had the same direction 
with the other. He could stand on it, but not walk without 
suffering. There was no appearance of any detached fragments 
of bone about the articulation : the trochanter was perfectly 
sound, and in its place. There was, at that time, no tender- 
ness in the groin, nor any inequality. The passive movements 
which I employed produced no pain, with the exception of strono- 
rotation outwards, and strong flexion of the thigh upon the 
pelvis. These movements produced some degree of pain, but 
not very considerable. There was no crepitus." 

Post-mortem Examination of the Seat of Injury. — " The 
muscles about the thigh were thin and wasted : the capsular 



348 EXTKEMITIES. 

ligament was thickened, but regular on the outside. On cutting 
into the articulation, there was no appearance of recent inflam- 
mation ; the neck of the thigh-bone was absorbed; just at the 
edge of the articular surface was a slight rising of the bone, 
scarcely visible to the eye, but perfectly sensible to the touch, 
which indicated the seat of the fracture. When the attempt was 
made to move the shaft of the bone upon the head, no motion 
between them could be perceived. A vertical section through 
the head and neck of the bone was then made : the place of the 
fracture was thus found to be indicated by a white line running 
across the neck of the bone, and having the thickness of the 
thirtieth of an inch. In one of the fractured sections, no 
motion could be produced between the head and neck of the 
bone ; in the other, slight motion existed. The preparation is 
in the Warren Museum." 



DISLOCATIONS. 

Dislocations are nearly as important to the surgeon as frac- 
tures. I do not propose to go into any detailed description 
with regard to them, but only to make a few remarks on cer- 
tain points which have seemed to me to be of special impor- 
tance. 

As a general rule, dislocations are rarely produced by a direct 
blow on the joint. Where they occur from this cause, they are 
usually accompanied with a fracture. 

I have never seen, nor do I know of, a case of simple dis- 
location of the hip-joint produced in this way. Dislocations of 
the shoulder-joint are described by authors as taking place either 
by falls on the elbow or hand, or from a direct blow on the shoul- 
der. Mr. Bryant, in Cooper's "Surgical Dictionary," states, 
that, "in thirty-one out of thirty-four cases, the cause of the in- 
jury was a direct fall upon the shoulder, either forwards, back- 
wards, or outwards. In two instances only of dislocation 
downwards, and in one of dislocation downwards and forwards, 
was the bone displaced by a fall upon the extended arm." 
M. Malgaigne says, on the contrary (p. 462 of his work on 
Dislocations), speaking of one of the most common dislo- 



DISLOCATIONS. 349 

cations, — the one under the coracoid process, — as follows: 
"Finally, in very rare cases, the sub-coracoid dislocation is the 
effect of a direct blow on the shoulder, the arm not being raised. 
Richerand appears to have observed one case in a quarryman, 
who, surprised by a caving-in of earth, struck the external part 
of the shoulder against a pillar of a gallery ; but we shall see 
that these sorts of falls produce particularly incomplete dislo- 
cations, and especially infra-coracoid dislocations ; and perhaps 
that of Richerand belongs to one or the other of these two 
categories." 

The error, probably, which has arisen, in speaking of these 
dislocations induced by a blow on the shoulder, is in not stating 
whether the arm is applied to the side, or raised at an angle 
from it. In the former position, it would seem almost impos- 
sible, by a blow from above, to drive the head of the bone down 
below the socket. In almost every case where I have seen dis- 
locations occur from a fall on the shoulder, the arm lying at the 
side, — as in persons who fall, like the intoxicated, without an 
effort to save themselves, — a crepitus was found to accompany 
the replacement of the head of the bone, Avhich was easily dis- 
placed again after reduction, as if the support from the front 
part of the socket had been broken away. In one case of dis- 
location, under the clavicle in front of the coracoid process, 
which is said by Malgaigne to be produced by a blow on the 
shoulder, the man was jammed between two heavy freight-cars, 
which doubled him up, as it were, dislocated his shoulder for- 
wards, fractured the collar-bone in three or four places, and 
fractured his ribs, driving them into his lungs. The head of 
the bone was replaced before I saw him ; but, learning the way 
in which the accident was received, I made investigation to see 
if crepitus was present, and found it, but not very marked. 

Dislocations of the elbow-joint usually result, so far as I 
have observed, from falls on the hand, or violent twists of the 
fore-arm, blows on the back of the elbow-joint producing frac- 
tures, or fractures accompanied with dislocation. 

Dislocation of the knee-joint, unless it is a compound one, 
I have rarely seen. Of displacement of the semilunar carti- 
lages of the knee-joint, I have seen a number of instances. 



350 EXTREMITIES. 

They have occurred from a twist of the limb, or from catching 
the foot in the carpet : and I have always replaced them by 
flexing the thigh on the body, the leg on the thigh; then, 
by giving a lateral or jerking motion to the joint, and suddenly 
straightening it, the cartilage has gone into place. 

In dislocations of the outer end of the clavicle, I have not 
witnessed much success in the treatment, nor much ultimate 
weakness of the arm by its remaining out of place, although its 
too free play may be a source of discomfort. Dr. Folts, of 
East Boston, has suggested a modification of Bartlett's appara- 
tus for broken clavicle, as a remedy for this accident, which is 
effected by an additional shoulder-strap over the injured shoul- 
der. 

I would mention here the following symptom, which is very 
frequent after recovery from dislocations of the shoulder-joint ; 
and, in fact, other accidents in which the deltoid muscle is in- 
volved. It is the want of power in raising the arm above a 
certain angle, which so frequently follows. I have often seen 
patients many months, and sometimes years, after a dislocation, 
who, having recovered all the other motions, are unable to raise 
the arm beyond an angle of 45° or 50°. In cases of straining 
of the shoulder, produced, for instance, by a person swinging 
himself off from a wharf to a ship, I have observed this symp- 
tom after a period of two years from the time of the accident, 
attended with much pain. In two instances, it was cured by 
keeping the limb at rest two or three months. In the early 
part of 1866, a lady consulted me for this reason, who, sixteen 
years before, was thrown out of a sleigh, and struck the upper 
part of her shoulder on the curbstone. She could elevate the 
arm to about 45°. It could be rotated freely inwards, to any 
extent, but scarcely any outwards. On the back part of the 
head of the bone, I discovered an osseous lump, which ap- 
peared to be the greater tubercle knocked backward. 

"This," by the way, Malgaigne says, "is often broken when 
the head of the bone is driven forwards under the clavicle by 
a direct blow." Lately, this lady, while exerting herself in 
packing a trunk, felt something give way about the deltoid 
muscle, followed by an ecchymosis ; showing, that, even after 



DISLOCATIONS. 351 

this lapse of time, the injury to its fibres had not been re- 
paired. 

In following the wards of Lisfranc, in Paris, I noticed a 
number of cases of injuries of the shoulder-joint, which he con- 
sidered anomalous, and which were supposed to be partial dis- 
locations of the shoulder. These patients had all received their 
injuries by a blow upon the joint itself : the head of the humerus 
seemed to be displaced slightly forward, or as if on the edge of 
the glenoid cavity. It could be easily replaced by a slight 
effort, but was at once displaced when abandoned to itself. 

Some time afterwards, I observed, in the " Medico-Chirurgical 
Review," a drawing of a case which had been considered one of 
partial dislocation, but in which it was shown that the front part 
of the socket had been broken off; thus allowins: a slio^ht dis- 
placement of the head of the humerus forward, and ending in 
the formation of a new socket a little in front of the old 
one. 

About this time, a sailor was brought into the Massachusetts 
General Hospital, who had fallen from the mast of a ship, and 
had received fatal injuries. Among others, there was apparently 
a partial dislocation of the shoulder. On examination, a dis- 
tinct ecchymosis was found on the external aspect of the joint ; 
and the front part of the socket had been broken off, so that the 
head of the humerus lay partially below the coracoid process. 

During several years in practice, before I fully understood 
the nature of the lesion, I observed cases of dislocation of the 
shoulder, in which, after reduction by the usual methods, the 
bone showed an unusual tendency to return to its former state 
of displacement. In these cases, I found, on a strict examina- 
tion of the patient, that the injury had been inflicted by a blow 
upon the joint itself. Latterly, I have occasionally met with 
cases of recent dislocation which have been brought into the 
Hospital on account of the supposed failure to effect reduction, 
but in which the real difficulty lay, not in replacing the bone in 
its socket (which was very easily effected), but in retaining it 
there after the removal of the artificial supports. I suppose 
these cases to be fractures of the edge of the socket, or its car- 
tilaginous rino', bv a blow on the shoulder. It is difficult, 



352 EXTREMITIES. 

however, to prove this by anatomical investigation, our oppor- 
tunities to do so beino^ rare. 

This fact is one of considerable practical importance. When 
a patient comes under our notice, with a recent dislocation of the 
shoulder-joint, he may be asked in what manner the injury was 
received. If by a blow on the shoulder, a bruised spot will 
generally be found ; and, if an ecchymosis also appears within a 
short time, either in front of the joint or along the side of the 
arm, the diagnosis of a fracture may almost certainly be made. 
If, on the contrary, the patient has received the blow on the hand 
or elbow, with the arm at the same time more or less extended 
from the thorax, we may expect to find a simple dislocation ; or, 
if there has been great violence, we may possibly find it com- 
plicated with fracture of the neck of the humerus. Impacted 
fracture of the head of the humerus, occurring from a blow on 
the shoulder, is the only injury likely to be mistaken for the so- 
called partial dislocation just noticed. Malgaigne mentions a 
displacement of the tendon of the long head of the biceps, as 
giving the appearance of partial dislocation. 

The most important part of the treatment of dislocation 
of the shoulder, with fracture of the socket, consists in retain- 
ing the bone in position after it has been reduced. This object 
is well attained by the use of Fox's apparatus for fractured 
clavicle ; the wedge-shaped pad in the axilla preventing the re- 
production of the dislocation. In old cases, with complete 
displacement, considerable force is often required to break up 
adhesions, which are generally more tenacious than in cases of 
old simple dislocation ; probably on account of the additional 
inflammatory action consequent upon the fracture of the socket. 
Greater care, and a longer persistence in the use of mechanical 
means, are also necessary to retain the head of the bone in its 
place while the new socket is in process of formation. In fact, 
I have seen the head of the bone displaced by a slight pressure 
with the thumb while being examined after reduction, the arm 
being at the time firmly bandaged to the body. In old dislo- 
cations, an entire loss of muscular power might also allow of 
this. 

I have had to treat several cases of dislocation of the shoul- 



DISLOCATIOXS. 353 

der, with fracture of the neck of the humerus. In two instances 
in which I was called while the muscles were still relaxed, and 
before the patient had recovered from the depressing influence 
of the shock, it was found possible to eifect reduction by making- 
extension of the shaft of the bone, at the same time working 
the separated head into its socket by firm pressure with the 
thumbs. In case reduction cannot be thus effected, it is still a 
question whether the shaft of the bone should be carried back 
into the old socket, so as thus to make at once the best practi- 
cable joint ; or whether it should be placed in apposition with 
the head, and an attempt made at reduction after such a lapse 
of time as may be thought sufficient for the union of the frag- 
ments to take place. The latter method was tried with success, 
by Dr. John C. AVarren, on a young man, whose case he re- 
ported in the "Boston Medical and Surgical Journal" for 1828. 
Immediate reduction haying been attempted in vain, fracture- 
apparatus was applied. After seven weeks, extension was made 
with pulleys, and the dislocation reduced. This case is quoted 
by Malgaigne, who considers the precedent worthy to be fol- 
lowed in similar cases. I also attempted the same treatment in 
a case which occurred nearly twenty years ago ; but, in the 
attempt to break up the adhesions which had formed during 
the six or eight weeks that had elapsed, the callus gave way, 
and the fracture was reproduced. The broken end of the bone 
was then placed in the glenoid cavity, and the patient recovered 
with a very useful arm. In another case which came under my 
notice, the arm had been paralyzed by fruitless attempts at reduc- 
tion. I saw the patient, in consultation with other surgeons, at 
the end of seven Aveeks, when it was decided to leave the broken 
end of the bone in the socket. I afterwards learned that the 
paralysis gradually passed off, and that the patient recovered 
the use of the arm. 

Dislocation of the hip-joint, so far as my own observation 
goes, may take place upon almost any part of the pelvis in the 
immediate neighborhood of the acetabulum. Durina' an at- 
tempt at reduction, made under ether, I have seen almost every 
kind of displacement imitated. In the course of my practice, 
I have had three cases of dislocations downwards and back- 

45 



354 EXTREMITIES. 

wards ; one of them in a boy of six years of age, the youngest 
patient in whom I have ever seen dislocation of the head of 
tlie femur. I have met with a dislocation of one thigh into the 
foramen ovale, the other thigh being dislocated upwards at the 
same time, with incomplete fracture of the neck of the bone ; 
the fractured portions separating just as the head had been 
restored to its place in the socket. 

I have only once seen a dislocation of the hip in the female, 
— a patient who came into the Hospital under Dr. Cabot, who 
reduced it ; and I believe that there is but one such instance re- 
corded in the work of Sir Astley Cooper on this subject. The 
rarity of this dislocation in women is a fact of great importance 
in distinguisliing between fractures, and displacements of the 
head of the thigh-bone. 

It is well known as one of the diagnostic marks of fracture 
of the neck of the femur, that the foot is turned outwards, and 
the limb shortened. In dislocation on the dorsum ilii, the limb 
is turned inwards, with a like shortening. As an exception 
to the rule in fracture of the neck of the thigli-bone, and as a 
point of resemblance to dislocation upon the dorsum ilii, I would 
refer to two cases already given of inversion of the foot in frac- 
ture of the cervix femoris in old women. I have also observed, 
in the course of the reduction of a dislocation on the dorsum, the 
toes become everted ; the head of the bone taking a position in 
front, so as to present most of the appearances usually given by 
a fracture of the neck of the bone. 

The use of ether has made a very great change in the prac- 
tice pursued in the treatment of dislocations of the hip, which 
can now be very frequently reduced by manual assistance only, 
thus enabling us, in many cases, to dispense entirely with pul- 
leys ; and, by successive movements of flexion, abduction, and 
-rotation, to restore the head of the bone to its socket with re- 
markable facility. 

Case CCYI. — Dislocation of the Shoulder-joint of eight 
weehs^ standing. Heduction. — February, 1864. A woman, 
42 years of age and in fair health, was taken, after the delivery 
©f a healthy child, with severe puerperal convulsions, lasting 



DISLOCATIONS . 355 

twenty-four hours. During this time, she was continually 
throwing herself violently about in the bed, unless restrained 
by attendants. After she had recovered from the convulsions, 
it was found that the left shoulder-joint was much swollen and 
bruised on its outer side, with an ecchymosis running down 
upon both the outer and inner sides of the arm. The arm was 
useless. At the end of six weeks, the swelling having subsided, 
it was discovered that a dislocation existed. Attempts were 
made, by manual extension, to reduce it, during which more or 
less crepitus could be distinguished. 

From tlie history of the case, — that is, from the fact of there 
having been great swelling, attended by ecchymosis, — I sus- 
pected that a fracture must have existed in addition to the 
dislocation. 

The head of the bone could be felt in the axilla, and, with 
the neck, seemed to be a little enlarged. Pulleys were applied, 
after the patient was thoroughly etherized ; and, the adhesions 
having been ruptured by forcible rotation of the limb, after 
strong extension, an attempt was made to carry the head into 
its place. Much crepitus was felt ; but the effort to restore the 
bone to its normal situation failed. The pulleys were again ap- 
plied, and powerful rotatory motion given to the humerus, so as 
to carry the bent arm through three-quarters of a circle. The 
knee was now placed in the axilla ; and, the pulleys being re- 
laxed, the head of the bone was pried into place. The arm was 
then confined to the body by a bandage. On a slight pressure 
being made upon the head of the bone with the fingers, it slipped 
partially out of the socket ; and this continued to recur when- 
ever the bone was reduced, until It was prevented by placing 
a large pad in the axilla. This arrangement was adopted 
throughout tlie treatment, that is, until the lapse of about four 
weeks, when it was found that the size of the pad could be 
somewhat diminished. The patient then went home, with direc- 
tions to continue the use of the apparatus until no farther dispo- 
sition to displacement should exist. 

October, 1864. — This patient consulted me again, now seven 
months since the reduction of the dislocation. She said that, 
once or twice after she returned home, the bone had slipped 



356 EXTREMITIES. 

out of place, but had been easily reduced ; and she thought that 
it was not yet in its proper position, as she could not make all 
the usual movements of the limb. On examination, I found the 
shoulder nearly as plump and round as the other, and, in fact, 
a little more prominent, from the habit of carrying it elevated 
during the long course of bandaging to which it had been sub- 
jected. The whole limb looked healthy, and the use of it was 
good, with the exception of the motions of elevation and ab- 
duction, which we often see impaired for a year or more after 
a simple displacement of the bone, or even when the muscles 
have been injured by a severe strain, witliout any dislocation. 
It might be mentioned, that no motion imparted to the head of 
the bone could reproduce the dislocation, as was the case but 
a few months before. 

Case CCVII. — Sub-coracoid Dislocation^ prohahly In- 
comiolete. — A large, powerful young man, who said that he 
was but 16 years of age, although apparently nearly ten years 
older, presented himself at the Hospital with an injury wliich 
he had received fifteen days before, having fallen from a height 
upon the deck of his ship. He was unable to use the limb 
much, and could not raise it. He said there had been but little 
pain and no numbness, and that the blow had been received a 
little below the most prominent part of the shoulder. At the 
point indicated, or rather a little below it, was a slight discol- 
oration. On the inside of the limb, in its low^er two-thirds, was 
an extensive ecchymosls. Under the acromion, the head of the 
bone could not be felt, and the roundness of the shoulder was 
lost. The deltoid muscle, however, was not on a stretch, as 
is seen in cases of ordinary dislocation. On elevating the limb, 
and exploring the axilla, the head was felt, although rather in- 
distinctly, and as if covered up by some plastic material. It lay 
directly under tlie coracoid process. The patient was advised 
to submit to an attempt at reduction, and was told, that, if 
he did not, the use of the limb ^vould be impaired for life ; but 
being very stupid, and suffering no pain, he declined to have the 
trial made. 

This case appears to be one of those in which the head 



DISLOCATIONS. 357 

of the bone seems to have been driven against the front part of 
the socket, breaking away its supports, and allowing the head 
to rest just in front of its natural position, forming there a new 
socket nearly on the edge of the old one. This injury is indi- 
cated, first, by the want of tension of the deltoid, which usually 
exists when the head of the humerus is caught under the edge 
of the socket; secondly, by the numbness met with, in most 
cases, from the pressure of the head of the bone upon the 
axillary nerves, where the dislocation is complete; and, finally, 
by the great ecchymosis on the inside of the limb, occasioned 
by the ruptured vessels about the injured socket, and which we 
do not often see, so far as my experience goes, in cases of sim- 
ple dislocation of the shoulder. An attempt at reduction, in this 
case, would probably have resulted in the breaking-up of the 
adhesions which had formed ; thus admitting of the replacement 
of the bone in its natural position, where, however, from the 
want of support, it would require the aid of mechanical appli- 
ances to retain it until a new socket should be formed about it. 

Case CCVIII. — Dislocation of the Head of the Humerus 
forward, to it li probable Fracture of the Socket. Reduction. 
— The following case exemplifies two facts. The first, of which 
I have before given one or two instances, is, that when a blow 
is received on the shoulder, the arm being at the side, and not 
extended, producing a dislocation of the humerus, it is generally 
accompanied by a fracture ; second, when a patient presents 
himself with a doubtful injury to the arm, the necessity of ex- 
amining carefully the whole upper extremity. 

A short, powerful Irishman, about ^h years old, applied for 
advice at the Hospital. Having requested the ward-tender 
to prepare the patients beforehand for examination, as there 
were a great many applicants, his shirt was removed. I at once 
perceived an unnatural condition of the shoulder; and, on ex- 
amination, found the usual signs of a dislocation forwards. The 
patient said that he had fallen, about five weeks before, striking 
on an iron grating, producing a severe contusion, followed by an 
ecchymosis on the outside of the arm. I asked him if he had 
had surgical advice. He at first said no, but afterwards stated 



358 EXTREMITIES. 

that he had received advice from a physician at the time of the 
injury, and advice at the Hospital about three weeks after. On 
inquiry of the house-surgeon, I learned that the man had been 
there, and had stripped up his sleeve as far as the elbow, and 
shown me a swollen arm, upon which, he said, he had received 
a severe blow. A liniment was prescribed, and he was told to 
call again. 

The patient was etherized, and the pulleys adjusted. The 
limb was then rotated, in order to break up the adhesions, 
which were heard to give way under the force applied. Consid- 
erable force was exerted before the head of the bone could be 
drawn outwards under the socket. The knee was then placed in 
the axilla, to serve as a fulcrum ; and, the arm being used as 
a lever, the head of the bone was restored to its place. The 
extension was now relaxed ; and, without moving the elbow 
from the side, I made a movement of rotation to ascertain the 
state of the socket. A cartilaginous crepitation was at once 
felt, and the head of the bone was again displaced. In old dis- 
locations of the shoulder, this occurrence is not uncommon 
after reduction, if the arm is raised at an angle of from 45° to 
90° from the body ; but I have seldom known it take place 
from the simple act of rotation, unless a part of its supports had 
been destroyed. The pulleys were again adjusted, the bone 
returned to its socket, and the arm secured to the side by a 
bandage. The recovery was good, but prolonged. 

Case CCIX. — Ca^e of Dislocation of the Shoulder haclc- 
wards , from Muscular Contraction. Reduction. — This dis- 
location is one of great rarity. Sir Astley Cooper gives two 
cases as having occurred in his hospital practice in the course of 
thirty years ; which, however, he speaks of as being dislocations 
on the dorsum of t\\Q scapula. M. Malgaigne has collected 
twenty-nine cases, eight of which were the result of convul- 
sions, like the present case. Out of a hundred and fifty-nine 
cases of scapulo-humeral luxation recorded at the Middlesex 
Hospital, three are assigned to this variety. Tliis case is the 
first of a dislocation of the shoulder backwards that I have seen 
at the Hospital. M. Malgaigne describes the dislocation under 



DISLOCATIONS. 359 

the head of outwards and hachivards. He also speaks of the 
difficulty of retaining the head of the bone. In one of Sir 
Astley Cooper's cases, it was found that the sub-scapularis mus- 
cle was torn away from its insertion into the smaller tuberosity 
of the humerus, so that the posterior muscles drew it backwards 
as soon as replaced in the socket. 

The subject of the present case was a man aged 46. He 
entered the Hospital, June 29, 1866. Before he removed his 
clothes, finding the elbow applied to the side, and not standing 
out from the body, as in other dislocations of the shoulder, I 
doubted its being dislocation. On examination, the following 
appearances were presented : — 

The coracoid process of the scapula was so prominent as to 
appear at first like the head of the bone. On the outside of 
this, the glenoid cavity was seen empty ; the acromion projected. 
Behind the acromion, and raised a little above its external 
angle, was the head of the bone, firmly fixed in its position. 
The arm seemed to be a little longer than the other ; but it was 
difficult to decide this by measurement. The fore-arm and hand 
retained their movements ; the arm itself could be carried off 
from the side only for a short distance, and its anterior and pos- 
terior movements were very limited. 

The accident had occurred seven weeks before, during an 
attack of convulsions, followed by an apoplectic state ; and, 
on account of this critical condition, attention was not given to 
the state of the shoulder until some time afterwards. It was 
not known whether he received any blow on his shoulder during 
the convulsions : but a slio-ht ecchvmosis was still visible at the 
bend of the elbow, and at the upper and anterior part of the arm. 

The patient being etherized, the arm was rotated freely, 
to break up adhesions ; and, the scapula being fixed, an at- 
tempt was made to force the head of the bone into the socket, 
by carrying the elbow backwards, and prying the head for- 
Avards ; but it could not be stirred from its situation. The 
movements of rotation were now repeated, followed by powerful 
extension ; and, on a repetition of the same process as before, 
the head was detached from its position, and replaced in the 
socket. This was verified by an examination made by all the 
gentlemen present. 



360 EXTREMITIES. 

The arm could now be carried freely in every direction. The 
head of the bone was quite movable in the socket ; and, on 
being seized with the fingers, could be easily displaced either 
forwards or backwards. This seemed owing partly to the entire 
loss of muscular power for retaining the head of the bone in its 
place ; and, possibly, from an inflammatory action, or the tear- 
ing away of the attachments of the sub-scapularis muscle, which 
took place in some of the cases recorded. 

The patient's arm was bandaged to his side, and a firm pad 
applied behind the head of the bone to prevent displace- 
ment. 

Notwithstanding these precautions, in the course of the night, 
the bone again became displaced, so that it was necessary on the 
following day to etherize him, and replace it, which was done by 
one of my colleagues ; my term of service having expired at the 
Hospital. The right arm was now confined behind the body 
for eight days, during which time the head of the bone re- 
mained in place. Being then brought back to its natural posi- 
tion, and bandaged firmly, in the course of the night it again 
became displaced. It was then replaced, and the arm confined, 
as before, behind the back; and he returned home on the 13th, 
promising to report in the course of a week. 

He showed himself once or twice more at the Hospital. The 
arm retained its position in the socket, and the motions of tlie 
arm were improved. 

Case CCX. — Dislocation of Shoulder of three months^ 
standing. Reduction. - — May 17, 1861, a seaman entered 
the Hospital, with a dislocation of his shoulder of three months' 
duration, which had taken place as follows : — 

While rounding the Cape of Good Hope, his ship encountered 
a heavy gale. A sea struck the vessel, while he was on deck, 
and knocked him violently against the tafi^rail. He received 
the blow on his arm just below the shoulder. The captain at- 
tempted to reduce the dislocation, but did not succeed; and, 
since then, the man had been using his arm as much as the 
limited motion would allow. 

On the day following his entrance, May 18th, the patient was 



DISLOCATIOXS. 361 

etherized, the adhesions being first broken up, as far as could 
be, by rotation of the humerus ; and, after extension and other 
manoeuvres, continued for half an hour, the head of the bone 
was restored to its normal position under the acromion. 

Owing either to the partial filling-up of the old socket, or 
what appeared to me a loss of substance in the front part of it, 
the head of the bone would not remain in place without sup- 
port. A pad was therefore placed in the axilla, and a retentive 
bandage applied. 

On the 1st of June, the bandage was removed, and slight 
motion of the arm advised. He gained slowly the muscular 
and nervous power, owing to the long time that the limb had 
been displaced ; but was sufficiently well, June 2 2d, rather more 
than five weeks after the reduction, to leave the Hospital, 
having a pretty good use of his limb. 

Case CCXI. — Dislocation of Shoulder, with Probable 
Fracture of Glenoid Cavity. — June 18, 1861. About six 
weeks before, while this patient, a man of 35 years, was standing 
in his store, he was seized with giddiness, and fell, striking upon 
his left shoulder. For two weeks after the accident, he felt 
pain and a sense of uneasiness about the shoulder, which was 
examined by several physicians, who could detect nothing ab- 
normal. At the end of the two weeks, as he was pulling on a 
rope attached to a limb of a tree, the limb sprang back ; and 
the rope, catching in his arm, gave it a severe twitch, thereby 
dislocating it. Several attempts had been made to reduce it 
before his entrance into the Hospital. 

On examination, there was the usual prominence of the 
acromion ; and the head of the humerus was felt under the cora- 
coid process. Having been etherized, the reduction was easily 
efiPected ; though, with slight pressure, the bone would slip back 
to its former position. 

In his first fall, the patient probably broke oiF the anterior 
edge of the glenoid cavity. This would explain the trouble he 
had after the first injury, the fragment acting as a foreign body. 
By means of a bandage, the head of the bone was kept in its 
place ; and patient made a good recovery. It may be remarked, 

46 



362 EXTEEMITIES. 

that, in these cases of old dislocation of the shoulder, the frac- 
ture of the socket is supposed from the manner in which the 
accident occurred. Secondary displacements would take place, 
from obvious reasons, if this fracture was present. In a recent 
case of dislocation, the practised surgeon cannot mistake carti- 
laginous for bony crepitus. 

Case CCXII. — Lateral Dislocation of the Elbow. — 
This accident is excessively rare, and the only case of complete 
lateral dislocation that 1 can find is one described and figured by 
Nelaton. 

Nov. 23, 1863. The patient was a tall, muscular man about 
25 years old, and, in wrestling with another man of about his 
own strength, was thrown violently down, his arm coming 
under him. On rising, the arm was powerless, and he supposed 
that the joint had been fractured. He was brought to my 
house in a state of great suiFering. Supposing that it was a 
case of a common dislocation of the elbow, I felt for the pro- 
jection of the olecranon through the clothes, but could not distin- 
guish it. Neither was crepitus produced by attempts at rotation. 
The clothes being removed, wdth some difficulty, as the man 
was in great pain, the condition of the limb could be observed. 
The fore-arm was very slightly flexed on the arm, but less so 
than in the dislocation backward, and was not so much fixed. 
The back part of the elbow was completely flattened, and none 
of the processes of the bones which enter into the joint were 
anywhere prominent. The breadth of the elbow was about one- 
third greater than natural. By manipulation, the articulating 
process of the radius, the olecranon and the internal condyle of 
the humerus could be distinguished in the mass ; but the whole 
anatomical condition of the parts was of the most perplexing 
nature. By extension, flexion, and rotation, after two efforts, 
the articular surfaces were restored to their natural position. 
The case did well. 

. Case CCXIII. — Fracture of the Arm just above the Con- 
dyles, of seven weeks' standing, imitating Dislocation of the 
Fore-arm backwards, • — 1866. I have lately had an opportu- 



DISLOCATIONS. 363 

nity of seeing a case of the above description in the practice of 
Dr. Cabot, one of my colleagues at the Hospital, and, with his 
permission, give it to show the deceptive appearances which may 
be produced after a fracture. 

The patient, a child of six years, was thrown down by a boy, 
and sustained what the surgeon in attendance considered, and 
wdiich undoubtedly was, a fracture of the humerus just above 
the condyles. 

Seven weeks after, the inflammation and swelling having sub- 
sided, he entered the Hospital to have what, on a cursory exami- 
nation, seemed to be a dislocation of the fore-arm backwards 
reduced. 

A more careful inspection was made on the next day, with 
the following result : On the front of the arm, there was a slight 
ecchymosis ; the fore-arm could be flexed to about a right angle ; 
and, just in front of the joint, the lower end of the shaft of the 
humerus projected, not sharp or rough, as described in recent 
fracture, nor so broad as we ordinarily meet in dislocation. On 
the inner side of this portion of the humerus was a rounded 
process, which felt very much like the inner condyle. On 
the outside of the elbow, the head of the radius could be felt 
behind the humerus. By careful manipulation just above it, the 
outer condyle w^as found, upon which it moved freely. The 
olecranon could be easily distinguished, displaced backwards, 
and on its inner side a portion of bone was felt. 

Flexion was good to only a limited degree, and there was no 
lateral motion, but the arm could be completely extended ; the 
two latter points constituting the chief difference between frac- 
ture and dislocation of the elbow. 

The diagnosis made was that of fracture of the humerus just 
above the condyles ; the upper fragment being forced down in 
front of the elbow-joint, and the lower fragment carried up 
behind the shaft of the humerus, to which it had become 
attached. Under ether, after a moderate amount of force had 
been used, the motions of the arm were somewhat improved. 

The appearances have been given in detail, from the fact, that 
the differential diagnosis between fracture and dislocation is gen- 
erally made when the injury is recent, and before the process of 



364 EXTREMITIES. 

repair has been set up. After the bones have united, in a frac- 
ture near a joint, with some dispLicement, it is often very diffi- 
cult, and sometimes impossible, to decide whether we have to 
deal with an unreduced dislocation, or a fracture with the bones 
united at an angle. 

Case CCXIY. — Dislocation of both Thighs: one^ into 
the Foramen Ovale; the other ^ on the Dorsum of the Ilium, 
with Fracture of the Cervix Femoris. Reduction. — The 
patient was brought into the Massachusetts General Hospital, 
having been crushed by the giving-way of a wooden house which 
he was engaged in moving, being struck upon the back as he 
was making an attempt to escape. The right leg first attracted 
attention. The thigh was fixed, slightly flexed on the body, 
standing off from it ; the toes pointing nearly forward, the limb 
apparently elongated. A deep hollow was felt in the region 
of the trochanter, which had itself disappeared. The man being 
etherized, and the pulleys adjusted, a gradually increased force 
was applied to extend the limb. A sheet was placed under the 
upper part of it ; and an assistant, standing on the table, directed 
to lift the limb. A slight rotation was then made to disengage 
the head of the bone, and it went into its place without any 
perceptible noise or action of the muscles. 

The right limb being replaced, it was now perceived that the 
left limb was distorted, and presented all the signs of a dislo- 
cation upon the dorsum ilii. It was firmly fixed, shortened, the 
toes inverted, and resting upon the upper part of the other foot. 
The trochanter was prominent, and drawn up from its place to 
within about three inches of the crest of the ilium. On making 
an effort to move the limb, an indistinct, but very decided, 
crepitus was perceived. 

The pulleys being adjusted, and ether administered, the limb 
was slowly and with much difficulty drawn down ; a slight rota- 
tory motion being given to it, when the head was on a level with 
the socket. It went into its place with a loud crack, which was 
heard by all the assistants. The limb now appeared, at first, to 
have regained its natural condition. As the effect of the ether 
upon the muscular system subsided, the limb gradually con- 



DISLOCATIONS. 365 

tracted, and the foot became slightly everted. An examination 
now being made, by rotating the limb, and placing the finger on 
the trochanter, it was perfectly evident to all present, that there 
was a fracture of the thigh-bone passing through the trochanter. 
The two limbs were therefore confined ; the right one by a 
weight attached to it, and a cradle placed over it. To the left, 
Desault's splint, as used at the Hospital, was applied. In ad- 
dition to the above injuries, two or three ribs on the left side 
were fractured. 

The best explanation of the appearances offered by the left 
limb is this : The violent crushing force dislocated the femur, 
at the same time breaking the neck of the bone. The separation 
of the parts was not, however, sufficient to prevent them from 
being replaced ; but the signs of complete fracture of the neck 
of the femur were at once produced, on the bone being returned 
to its socket. 

The subsequent history of this case is not without interest. 
The patient, from the time of his admission, had complained of 
his chest, where his ribs Avere broken. One night, some weeks 
after entrance, great difficulty of breathing came on ; and, upon 
examining the chest, it was discovered that a congestion of the 
posterior part of both lungs had taken place, such as has before 
been observed at the Hospital in patients who for a long period 
of time have been confined on the back without movement, after 
serious injuries to the lower limbs. From this affection he 
very gradually recovered. 

At the end of two months, he left the Hospital well. The 
motion of the right limb was natural. The left leg was a little 
shortened. The motions of the hip-joint were limited ; on ex- 
amination, the trochanter was found irregular at the point of 
fracture. As it had been thought possible that the head of the 
femur might have been left on the dorsum of the ilium when 
the complete fracture of the limb took place, search was made 
for it ; but it could not be found there. 

Case CCXV. — Case of Dislocation on Dorsum Hi i^ with 
JProbahle Fracture of the Socket, Reduction. Frequent 
Hecurrence of the Dislocation. — A man was brought into 



366 



EXTEEMITIES, 



the Hospital with a dislocation on the dorsum ilii, which was 
caused by a wagon passing over liim, the limb being at a right 
angle with the body. Ether was given, the pulleys applied, 
and the dislocation reduced. On raising the limb slightly, to 
examine it, it at once slipped out of place, and was again 
reduced. This experiment was once or twice repeated, with the 
same result. Dr. S. D. Townsend, who saw the man, verified 
the fact. Shght, though not very marked, crepitus attended 
the movements of the joint. From fear of displacement, and 
with the idea of a fracture of the edge of the upper and back 
part of the cotyloid cavity, the limb of the patient was kept 
rigidly confined in Desault's apparatus, and his desire to re- 
turn home resisted. The precautions taken in this case were 
afterward shown to be not without reason. About three weeks 
after the accident, during my absence from towm, the patient got 
out of bed, and, while resting on the injured limb, attempted to 
turn around, thus giving a slight twist to the hip-joint. The 
bone immediately slipped from its socket. This accident after- 
ward, in the course of the next week, recurred a number of 
times from simple motions made by the patient while in bed. It 
was then determined to put on a permanent splint, and allow it 
to remain for several months. This had the desired effect, and 
the patient was seen by me some months after leaving the Hos- 
pital : the joint was then slowly regaining its mobility. 

During the treatment, the patient was very desirous to return 
to his home, but was persuaded not to. Had he done so, and 
had the dislocation been reproduced (as it was very likely to 
have been), it might easily have been urged that the dislocation 
had never been reduced. 

Case CCXVI. — Dislocation of the Hip-joint, with other 
Injuries. — December, 1851. A man, about 30 years old, was 
burled under a bank of earth ; and, on being dug out, was 
brought, about four hours after the accident, to the Hospital. 

On examination, it was found that he was laboring under a 
slight concussion of the brain ; that the right hip was dislocated, 
the limb being inverted, and shortened two and a half inches. 
The left testicle had been torn out from the scrotum, and hung 



DISLOCATIOXS. 367 

suspended by the spermatic cord. It was covered with gravely 
and the external tunic was so dry from exposure as to crackle like 
parchment. As the vessels still continued to pulsate, I deter- 
mined to make efforts to preserve it. It was therefore tempora- 
rily enveloped in a compress, wet with warm water ; after which 
the patient was placed under the full influence of chloric ether, 
with a view to the reduction of the dislocation. The force of 
the pulleys being applied, although a perfect state of relaxation 
from the effect of the anaesthetic agent seemed to exist, it re- 
quired continued effort, for ten or fifteen minutes, before the 
the muscles concerned in the dislocation began to yield. The 
limb was gradually brought down; and, when the head of the 
bone came opposite the socket, upon a slight rotatory move- 
ment, it slipped in with a distinct report. On moving the limb 
after the reduction, an uncommonly loud cartilaginous crepitus 
could be heard ; and this symptom, in a modified form, con- 
tinued for five or six weeks after the accident, even when he was 
sufficiently recovered to walk about the ward. 

Attention was next o^iven to the testicle. The scrotum havinof 
strongly contracted, it was found to be a matter of some diffi- 
culty to return it, but it was finally effected by seizing the scro- 
tum with the fingers, and then forcibly crowding in the testicle 
through the wound with the thumbs, confining it thus until two 
or three sutures were made in the integuments. 

The patient, when last seen, two months after the accident, 
was recovering the use of the injured limb. The wound in the 
scrotum had healed well, and the testicle seemed to have suffered 
but little from the exposure it had been subjected to. 

The application of the extending force, made from the ankle, 
was found more convenient than by the ordinary method from 
the lower part of the thigh. No subsequent inconvenience was 
experienced by the patient in the knee-joint. He had some pain 
and swelling in the ankle-joint for a number of days after the 
injury ; but whether it resulted from the accident, which was 
a complicated one, or was in any way connected with the man- 
ner in which the extending force was applied, it was impos- 
sible to determine. 



368 EXTREMITIES. 

Case CCXYII. — Dislocation on the Dorsum Hii, of 
tiDenty -three days' standing, Heduction. — A man 36 years 
old, of strong muscular development, was attempting to raise 
another who was lying across a railroad track. On making the 
effort, he fell ; the weight of the lifted man coming against his 
pelvis and left thigh. He was unable to rise, and was taken to 
a neighboring house, where his hip was examined. The injury 
was supposed to be a sprain. He remained in bed for twenty- 
three days ; and, as the limb did not recover, he was advised to 
go to the Hospital. Doing so, he walked a mile and a quarter 
to the railroad station. He came by the train to Boston, and 
entered the Hospital, March 13, 1862. On making an exami- 
nation, I at once perceived that the limb was not in its natural 
position ; and that the symptoms of a dislocation upon the dor- 
sum ilii existed. The limb was shortened about two inches ; 
the trochanter being about that distance nearer to the crest of 
the ilium than that of the opposite side, and the toes inverted, 
but not lying across the instep of the other foot ; there being 
this peculiarity, that the legs stood off from the thigh, forming 
an angle with it, and giving him a knock-kneed appearance. 
The whole limb was much more movable than I have generally 
observed in a case of dislocation. This may possibly have arisen 
from the efforts which he had made to produce motion, under 
the impression that it was only a sprain. On turning him on 
his face, the nates of the injured side appeared much broader 
and rounder than on the other side ; and, where the hollow 
usually exists behind the trochanter, an elevation was per- 
ceived, which on examination appeared to be the head of the 
bone, which rotated when the necessary movements were given 
to the femur. 

The patient was etherized to the point of total relaxation of 
the muscles, and pulleys were applied, and the limb drawn down 
to the same length as the other. An attempt was now made to 
turn the head of the bone into its socket ; but although, at the 
efforts at rotation, a tearing sound was heard, as if strong adhe- 
sions were being broken up, yet the bone could not be forced 
into its socket. An effort was then made to reduce it by Dr. 
Keid's method. This also failed ; the only effect being to carry 



DISLOCATIOXS. 369 

the head of the bone around the socket, and lodge it in tlie fora- 
men ovale. From this position, it was easily brought back to 
its original situation on the dorsum. The pulleys were now re- 
adjusted, and the limb again brought slowly down, so as to bring 
the head opposite the acetabulum ; and, the pulleys being re- 
laxed, a sudden twist and lift was given to the bone, which 
went into its proper place with a jerk. The limb at first, 
after the reduction, had rather an unnatural appearance, being 
seemingly longer than the other, so that I thought that possibly 
it might have again slipped under the socket ; but, on moving 
it, I found those free motions which can only be given by a bone 
in its natural position. The apparent length of the limb arose 
from a deviation of the pelvis, it having been three weeks in a 
strained position. 

Case CCXVIIT. — Dislocation of the Hip upon Dorsum 
Ilii. — June 16, 1859. The patient, a stout man of 23 years, 
while standing on the track of a railroad, was struck from be- 
hind in the pelvic region by a freight-car, thrown down upon 
the track, and dragged some distance. On examination, the 
dislocation was evident ; the ri^ht leo' beino- shortened two and 
a half inches, drawn up and thrown over the left, the foot in- 
verted, and the head of the femur easily distinguished on the 
dorsum ilii. 

The dislocation was readily reduced by the "flexion method," 
and the patient made a rapid recovery. 

Case CCXIX. — Perineal Dislocation of Hip- joints ivith 
Eversion of Foot. — A man, 35 years of age, while standing 
nearly erect, was knocked down by the caving-in of a bank 
of earth, and was seen by me two hours afterwards. He was 
thrown forward on his left knee, with the thigh much flexed 
on the pelvis. Did not know what the position of the foot 
was at the time of the accident. 

The left thigh was found to be flexed on the pelvis, at an 
angle of about 70°, firmly fixed, and about two and a half 
inches shorter than the other. The foot was everted. Near 

47 



370 EXTREMITIES. 

the tuber ischii was a projection. There was considerable swell- 
ing about the hip. 

The patient being etherized, extension was made by pulleys, 
at first in the axis of the thigh, and the limb rotated, but with- 
out effect. Extension being again made, the knee was de- 
pressed, and the upper end of the bone lifted forwards to the 
socket. This manoeuvre brought the upper end of the bone 
forward upon tlie pelvis above the socket, and straightened the 
thigh, the foot being everted and the limb shortened. 

Strong extension was next made in the axis of the body, the 
thigh rotated inwards, and, after slipping by the socket many 
times, the head of the femur snapped into its place. After some 
ecchymosis and swelling, the case terminated favorably. 

Case CCXX. — Dislocation on the Dorsum of the Hiura. 
Heduction. — An intoxicated man was brousfht into the Hos- 
pital, in the first week of June, 1859, having been caught under 
a train of cars backino^ into the station-house. The riofht femur 
lay across the opposite thigh, so that the internal part of the 
right knee touched the left patella ; the leg was a little bent 
upon the thigh, and the foot, slightly inverted, rested on the in- 
step of the other. The trochanter was felt a little above the 
acetabulum ; and the head of the bone, a little above and be- 
hind it, was indistinctly felt under the muscles. The thigh was 
immovably fixed, so that it could be seized near the knee-joint, 
and the patient almost turned over by it, without producing any 
motion of the limb. 

Having fully etherized the man, I first attempted to reduce 
the dislocation, by Reid's method ; viz., by strongly flexing the 
thigh, and making the knee describe a segment of a circle over 
the abdomen, thus sweeping the head of the bone partially 
around the socket. The seat of the dislocation was altered, but 
the head of the bone was not reduced. The limb was now 
seized gently by the ankle, and easily drawn down, till, when 
opposite the socket, a noise was heard as if it might have been 
reduced, but not of that decided character to satisfy me that it 
was so. Every person about thought it had been returned to 
its place. On letting the limb go, it seemed to have the natu- 
ral direction, but was evidently a little shortened. 



DISLOCATIONS. 371 

The limb was then again seized ; and, being dragged down, 
I put my hand behind tlie trochanter, gave it a little lift, and it 
went at once, with an unmistakable report, into its place. Mo- 
tion could now be given to the limb, in every possible direction, 
without throwing it from its situation. 

Case CCXXI. — Perineal Dislocation of the Hip-joint. 
Reduction. — 1851. A young man, about 20 years of age, 
was struck on the outside of the thigh, and thrown down, by 
a bundle of hay which fell on him from a loft. On his being 
taken up, it was discovered that the right hip-joint was dislo- 
cated ; and I was requested by his pliysician to see him. 

I found the patient lying on his back, the thigh standing out 
laterally from the trunk, and forming a right angle with it. At 
the spot usually occupied by the trochanter, a deep hollow ex- 
isted. The head of the bone could be felt on the ascending 
branch of the ischium, and might at first easily have been mis- 
taken for the tuber ischii. Tlie patient would not allow any 
examination to be made until he had been placed under the 
influence of ether. 

After the patient was etherized, the pulleys were adjusted, and, 
on the first effort at traction, the head of the bone slipped around 
the socket, producing the appearance of a dislocation into the 
ischiatic notch. The force of the pulleys was then increased ; 
and the head of the bone was quickly brought over, and went 
Into its place with a distinct report. On the removal of the 
extending power, the limb was found to have recovered its 
proper length and motions. 

A few years before the above, I had the following case : A 
gentleman, 60 years of age, fell from the third story of his store, 
alighting on his knees among some bales of goods. The effect 
was to produce a displacement of the right thigh, attended by 
phenomena like those observed in the preceding instance. The 
patient was etherized, and the limb replaced by manual force, 
without the aid of pulleys, the system being depressed at the 
time by the accident. 



372 EXTEEMITIES. 

Case CCXXII. — Appearance of a Dislocation of the 
Hip-joint, after nearly forty years. — This case is one of un- 
common interest. The subject of it was a gentleman, about 30 
years of age, who, in the latter part of the year 1821, applied 
to Dr. J. C. Warren on account of an injury to his hip-joint, 
which, he stated, had been injured twelve weeks before in the 
following manner. He was riding a spirited horse, when the 
animal suddenly reared and fell backwards upon him, the weight 
of the horse being received on the left thigh ; the patient having 
fallen on his back, as he said, a little inclined to the left side* 
On attempting to rise, he found himself crippled. 

After a careful examination of the case, it was declared to 
be a dislocation, and the patient was not encouraged to hope 
much from an operation. He persisted, however, in having an 
attempt at reduction made ; and, after a consultation with the 
other medical officers of the Massachusetts General Hospital, it 
was agreed that this should be done. The effort failed, after all 
the ordinary means had been resorted to. About a week after- 
wards, the patient applied to another surgeon, who gave an 
opinion similar to that given by Dr. Warren, and made another 
attempt at reduction, but without success. Finally, he was 
induced to apply to a professed bone-setter, who made a third 
attempt, with the same result. Immediately after the accident, 
he had, it seems, called in two practitioners in the neighborhood, 
who made attempts at reduction, and supposed they had suc- 
ceeded in replacing the bone. 

About a year subsequently, contrary to the advice of Dr. 
Warren, a suit for malpractice was brought, by the patient, 
against the two surgeons who were originally called to the case. 
After one or two trials, the suit was withdrawn, the jury having 
disagreed, principally on account of a conflict of surgical testi- 
mony. 

In September, 1858, I received a letter from Dr. Greeley, 
of Ellsworth, Me., the physician of this patient, stating that he 
was at the point of death ; that his friends were both willing 
and desirous to have the case investigated, and that he himself 
had always expressed the wish that this should be done. On 
the receipt, a short time after, of the telegraphic despatch an- 



DISLOCATIONS. 373 

nouncing his death, Dr. H. K. Oliver, at my request, proceeded 
to Ellsworth ; and, after taking note of the external appearances 
of the body, separated the pelvis and the upper third of the 
thighs, and, by permission of his family (it being impossible 
to make a satisfactory investigation on the spot), brought the 
portions thus removed to Boston. Here, he made a careful 
dissection of the soft parts, on the affected side ; and subse- 
quently, these tissues having been removed by maceration, made 
a thorough examination of the bony structures. 

The following is his report of the examination of the body, 
the dissection, &c. : — 

"The body, with muscular and adipose tissues well developed, was 
lying on the bed, the shoulders being slightly raised. The lower ex- 
tremities were on a line with the body ; the heels being together, and 
on the same level. The limbs were therefore, to the eye, of equal 
length. The right side of the pelvis appeared to be somewhat lower 
than the left. The right foot varied but slightly from the perpendicu- 
lar ; the left turned out at an angle of 25° or 30°. The left knee was 
raised, so that the thigh made with the plane of the bed an angle of 
about 15°. The right knee being raised to the level of the left, a 
difference of two inches in the length of the limbs was noticeable. It 
was difficult, on account of the great amount of adipose tissue, to 
compare the length of the limbs by measuring from the anterior su- 
perior spinous processes of the ilia. The movements of the left thigh 
were limited, and confined exclusively to flexion and extension ; no 
motion whatever being perceived in attempts at abduction and adduc- 
tion. Extension of the leg was impossible, even after division of the 
tendons of the flexor muscles of the thigh. There was consequently 
a permanent flexion of the thigh upon the body, and of the leg upon 
the thigh. On the upper and inner part of the thigh, a large, hard 
mass could be felt, not existing in the corresponding locality on the 
right side. This was subsequently found to be the new bony socket. 
The body being turned over, the flatness of the left hip, as compared 
with the right, was very marked. On examination, a hard, round- 
ed body, subsequently found to be the trochanter major, was felt 
lying rather deep below the level of the trochanter of the right 
side. 

" In the dissection of the left hip, all the muscles, large and small, 
belonging to this region, were found, but noticeably less full in sub- 
stance, and of a less healthy color, than those of the right side. The 



374 EXTREMITIES. 

change of direction taken by them, brought about by the change of 
the point of insertion, — namely, the trochanter major and the up- 
per part of the thigh-bone, — was of course apparent. The gluteus 
minimus, as it passed over what remained of the acetabulum to reach 
its point of insertion, was firmly bound down to the ligament which 
covered the cavity by strong fibrous tissue. The obturator externus 
appeared to be reduced to a few fibres, arising from the ramus of the 
ischium and pubes. The cartilaginous, and, apparently, part of 
the osseous, rim of the acetabulum was absorbed. Stretched over 
what remained of the cavity was what appeared to be a part of 
the old capsular ligament, still partially enclosing the neck of the 
displaced bone. Beneath this ligament, and filling up the acetabulum, 
was a dense mass of adipose and fibrous tissue. Encompassing the 
new socket was a tough fibrous layer, which, as it surrounded 
the neck of the bone, assumed all the density and strength of a true 
capsule, with perhaps even greater thickness. No line of division 
between the new and the old capsular ligament just referred to could 
be detected. Upon dividing the capsular ligament, a ligamentum 
teres was found, fixing the head firmly in the socket, and receiving 
the nutrient vessels through a notch in the same relative position, 
namely, in the anterior part of the cavity, as in the true acetabulum. 
The articular cartilage of the new socket was wanting in that smooth, 
shining appearance, characteristic of articulating surfaces general- 
ly. That of the head of the bone was much less uneven. Besides 
the round ligament, a few small fibrous bands were seen attaching 
the head of the bone to the socket anteriorly. Upon examination 
of the interior of the pelvis, the thyroid foramen was found to be 
nearly obliterated by the rounded base of the new socket ; but it still 
retained its membrane stretched over the intruding bony cup. 

" Since maceration of the soft tissues, the following points are 
to be remarked in the bony structures : — 

" An adventitious socket for the head of the thigh-bone is formed 
below, and a little in advance of the acetabulum on the left side. 
This socket fills up the greater portion of the thyroid foramen, and is 
bounded as follows : Superiorly, by the body of the pubes and the ace- 
tabulum, the cavity of the latter being encroached upon by the adven- 
titious socket to the extent of one-half of its area ; posteriorly, by the 
body of the ischium, upon which the socket rests without leaving any 
part of the thyroid foramen visible ; inferiorly, by the rami of the 
ischium and pubes, leaving no part of the foramen visible there ; 
anteriorly, by an irregular, crescent-shaped portion of the foramen, 



DISLOCATIONS. 375 

one and three-quarter inches in length, by an average breadth of 
one-quarter of an inch. The major part of the socket is of one 
piece ; but there are four separate pieces of bone of different sizes, 
the largest of which measures two inches in length by an average of 
one inch in breadth. These loose portions being fitted in the places 
where they appear to belong, the socket has an average outside diam- 
eter of three inches, and a depth of two inches. The substance of its 
parietes is quite firm, but irregular and rough externally, and some- 
what rough internally. The opening through which the nutrient 
vessels passed from the interior of the pelvis into the cavity of the 
joint is seen at the anterior portion of the fundus of the socket. 

" Where the socket is united with the ischium and the rami of 
the ischium and pubes, bony matter has been deposited in limited 
amount, so that a furrow extends from the old acetabulum posteriorly, 
round to the lower portion of the crescent-shaped opening anteriorly : 
but, upon the superior aspect, where the weight of the body was to 
be supported, the interval between the socket and the adjoining por- 
tion of the pelvis is entirely filled up. Here, in fact, is seen a firm, 
strong buttress, thrown across from the body of the pubes and the 
pubic portion of the ilium downwards and outwards, spreading over 
the whole superior surface of the socket quite to its outer edge. On 
examining the interior of the old acetabulum, its cavity, anteriorly, 
is seen to be considerably encroached upon by the posterior border 
of the buttress just described ; and, posteriorly, by a second but- 
tress, much smaller than the one mentioned, thrown down upon the 
socket from the posterior portion of the acetabulum. 

" The head of the left femur is much larger than its fellow of the 
opposite side, and its surface quite rough. Its greatest circumference 
is six inches. From the head of the bone, along the neck anteriorly 
and superiorly, is thrown a ridge of bone nearly reaching the trochan- 
ter major. This adds materially to the circumference of the neck, 
which is five and one-eighth inches ; that of the neck of the opposite 
side being four inches. 

" The most careful scrutiny fails to detect signs of previous frac- 
ture anywhere, either in the pelvis or in the femur." 

RemarJcs. — The most important point which Dr. AVarren 
was called upon to decide in this case was whether a dislocation 
of the bone existed or not. His opinion was that a dislocation did 
exist. The defendant in the suit, however, obtained a disagree- 
ment of the jury by the testimony of a distinguished surgeon, 



376 EXTREMITIES. 

who expressed a decided opinion that there was not and never 
had been a dislocation, but that the original injury was a frac- 
ture of the pelvis. It will be seen that no signs of any fracture 
having occurred are to be found in the specimen, but that the 
injury was what Dr. Warren supposed it to be, — a simple 
dislocation. 

The question was made very prominent in the trial, whether 
the species of dislocation of the hip which Dr. Warren supposed 
this to be, — namely, downwards and backwards, with the head 
of the bone lying on the ischium, near the lesser ischiatic notch, 
— ever existed ; and the work of Sir Astley Cooper was brought 
forward in proof that such a dislocation, although mentioned by 
some authorities, could not take place. Dr. Warren, however, 
did not understand Sir Astley to assert that this dislocation 
could not take place. Moreover, he felt, that in any case the 
evidence of his own senses should ratlier be his guide ; and, as 
he was also of the belief that there was no depression at any 
point about the acetabulum in which the head of the bone could 
not, exceptionally, be lodged, he persisted in his opinion that the 
dislocation backwards and downwards was within the bounds of 
possibility, and that the dislocation in question was of that 
description. In this belief, he had the countenance of the con- 
sulting surgeons of the Massachusetts General Hospital. 

Sir Astley, at that period, did not acknowledge the existence 
of this species of displacement of the hip-joint ; yet, in later 
editions of his work, published by Bransby Cooper, one or two 
cases are related as having afterwards occurred to him : and, in 
the edition of Sir Astley Cooper on Dislocations, published by 
the Massachusetts Medical Society, two cases of this injury are 
described, the specimens of which I had the opportunity of see- 
ing abroad ; one, through the politeness of Mr. Edward Stanley, 
the distinguished surgeon of St. Bartholomew's Hospital ; and 
the other, by the kindness of M. Robert, in Paris. In the 
latter case, the dislocation was partial, with the head of the bone 
resting on the socket. The dislocation downwards and back- 
wards is, however, at the present day, very fully acknowledged, 
and I have seen it in my own practice ; while Mr. Erichsen, in 
the last edition of his valuable work, has placed it among his 



DISLOCATIONS. 377 

four forms of dislocation, considering the dislocation upwards 
and backwards into the ischiatic notch as simply a different form 
of the dislocation upwards on the ilium. 

A few %vords as to the reasons which influenced Dr. Warren 
in his decision as to the kind of dislocation will be of interest 
here. The limb was lengthened ; the displacement was there- 
fore downwards. The next point was to determine whether this 
displacement was downwards and forwards into the foramen 
ovale, or downwards and backwards in the vicinity of the lesser 
ischiatic notch. The inclination of the foot and leg were such 
as to suggest to Dr. Warren the possibility of a displacement 
into the foramen ovale ; but the phenomena w^ere not so marked 
as to impress this species upon his mind to the exclusion of the 
displacement downwards and backwards, since he was of the opin- 
ion, that the position assumed by the limb might be varied by 
circumstances, being influenced by the degree and direction of 
the dislocating force, as well as by the subsequent condition 
of the capsular ligament. 

In this condition of thins^s, the head of the bone havino^ been 
diligently sought for at the inner and upper part of the thigh, 
and not detected there, but a hard, round body being distinctly 
felt below and behind the acetabulum, the head of the bone was 
thought by Dr. Warren and his confreres at the Hospital, to 
be lying behind and upon the lower part of the body of the 
ischium, in the vicinity of the lesser ischiatic notch. 

The dislocation as it now appears is not as it was described 
by Dr. Warren ; but the socket for the head of the bone lies 
almost immediately under the old acetabulum, perhaps a little 
forward of it. The cause of the deception, it wdll be surmised, 
lies in the fact, that the head of the bone found its resting-place 
almost immediately under the acetabulum, at the posterior part 
of the thyroid foramen, and in contact with the body of the 
ischium. Such a position of the head would render its detection 
anteriorly quite difiicult, even in very thin persons. 

The specimen, beautifully prepared by Dr. Oliver, may be seen 
in the cabinet of the Warren Museum of Natural History. Its 
appearance is faithfully represented in the annexed engraving, 
copied from a photograph. Above the adventitious socket lies 

48 



378 



EXTREMITIES. 




IIP'"' 



what remains of the acetabulum. Anteriorly is seen the cres- 
cent-shaped portion of the thyroid foramen, and the notch de" 
scribed as admitting the nutrient vessels of the joint. The 
larger buttress, described by Dr. Oliver, is perceived above the 
new socket, and anterior to the acetabulum. The change in 
the appearance of the head of the thigh-bone of the affected 
side is very faithfully delineated. 

The specimen, aside from the interest as connected with the 
trial, is exceedingly instructive in several respects. It is most 
curious to observe, that, in the deposition of the bony matter 
in the formation of the new socket, a distinct interval is left 
for the entrance of the nutrient vessels. 

The firm, strong buttresses which nature has provided are 
found just at the points where they are needed in the support 
of the body. The depth of the new socket is quite remarkable, 
and will explain in a measure the impossibility of abducting or 
adducting the limb ; the edges coming so far forward on, and 
encompassing so closely, the neck of the thigh-bone, as to make 
any such action impracticable. 



Case CCXXIII. — Dislocation of the Thigh into the Fo- 
ramen Ovale. Reduction. — In the early part of May, 1859, 
I was called to see a man who had received an injury of the hip- 



DISLOCATIOXS. 6(\) 

joint, also other injuries, by the fiill of the wall of a house. 
When I arrived, he was lying on his back, with his left leg 
flexed on the pelvis, and standing off from the other at an angle 
of about 45°. A slight hollow was perceived at the seat of the 
trochanter, and the foot was slightly everted. Taking hold of 
the affected bone, I found it in a great degree fixed; and, the 
foot being everted, I at once recognized a dislocation into the 
foramen ovale without further examination, knowing that no 
other injury could present these symptoms, unless it were a frac- 
ture of the neck of the thigh-bone, in which case there would 
have been a certain degree of mobility of the injured limb. 
Farther examination also was impracticable, the patient having 
his clothes on, lying in the street, and making the greatest out- 
cry on the slightest attempt to determine the nature of the in- 
jury. In addition to the above dislocation, he had a fracture of 
the lower end of the radius of the left arm, and a deep cut on 
the right temple. 

He was placed on a litter, and conveyed to the Hospital, 
where I almost immediately followed. He was etherized, and 
the dislocated bone, with very slight manipulation, slipped into 
its place. The patient was kept in bed about three weeks by 
his other injuries, but, on getting upon his feet, recovered rap- 
idly. The fractured radius, which was much displaced, was 
treated with the splint contrived by Dr. Bond, of Philadelphia, 
for that injury, which, for comfort and efl&ciency, is superior to 
any one that I know of for the treatment of this troublesome 
accident. 

Case CCXXIY. — Dislocation into the Foramen Ovale of 
four iceeks' standing^ icith other Injuries, deduction. — 
Oct. 9, 1861. A young man, 19 years of age, was brought 
into the Hospital, having, twenty-seven days before, fallen from 
the foreyard of a ship, while at sea; striking first on the roof 
of the cabin, and from thence slipping off, and striking the rail. 
By the first blow, the hip was dislocated ; and, by the second, 
the right arm was broken in three places, viz., the head of the 
humerus, the olecranon, and the wrist. The bones of the arm 
had united when he entered the Hospital ; the joints being rigid, 



380 EXTREMITIES. 

and the shaft of the humerus much in advance of the head of 
the bone. The patient was in rather a feeble state, and had 
gone through much suffering at sea; for four days after the 
injury there being a suppression of urine. The left thigh was 
out of its place, the knee was bent, the shaft of the femur pro- 
jected forwards, forming an obtuse angle with the body. The 
toes presented almost directly forwards. The trochanter was 
not prominent, as on the opposite side ; but there was no hollow. 
At the upper and inner part of the thigh, a prominence could 
be felt, not perceived on the other side ; and this could be dis- 
tinctly felt in the rectum, and was undoubtedly the head of the 
bone. 

The patient being fully etherized, the thigh was seized, and 
efforts made to break up any adhesions which might have been 
formed, by making motions of flexion and rotation. By these 
manipulations, the head of the bone was dislodged from its 
position, and slipped up on the pubis, but would not enter 
the socket. On further efforts being made, it slipped round 
under the socket, and finally lodged on the dorsum ilii. In the 
course of the reduction, the appearances presented by all the 
different dislocations of the hip-joint were imitated. The pul- 
leys were now^ applied ; and the limb being gradually drawn 
down, when opposite the socket a movement of rotation was 
given it, and it slipped in. After the reduction, a rigidity of 
the muscles on the part of the thigh still gave it an unnatural 
look, as if it might be out of its place ; but the restoration of 
an equal length to the other, and the free motions which could 
only take place with the head of the bone in the socket, dispelled 
any doubts. 

The feet were then bound together, and the patient was put 
to bed. When seen, an hour after, the limb again projected 
forwards, as before the operation ; and it was said that it had 
assumed that position after some struggles made by the patient 
in coming out from the effects of the ether. A little force, being 
applied to it, brought it down to a flat position in bed. While 
under the ether, flexion was given to the stiffened joints of the 
upper extremity. 

The patient complained much of pain in the upper part of the 



DISLOCATIOXS. 381 

thigh, and required sixty drops of elixir of opium to make him 
sleep. 

On the folloAving day, there was a suppression of urine, as 
had occurred after the accident. He gradually but completely 
recovered the use of all his joints in about a month after the 
reduction. 

Case CCXXY. — Dislocation of Thigh, with Fracture of 
the Acetabulum. Death. Autopsy. — A strong, robust, 
though intemperate man, 36 years of age, fell from a roof, 
striking on his right side, and was carried to the Hospital. The 
following is the report : " On entrance, the patient lies on 
the injured side. When placed on his back, it was found that the 
right leg was shortened, the knee semi-flexed, and the foot in- 
verted. The patient being etherized, the thigh could be flexed 
at a right angle witli the abdomen. Crepitus could be heard 
about the head of the bone. By continued exertion, the limb 
was extended to within half an inch of the length of the sound 
limb, and Desault's splint applied." 

The day following, the patient died of delirium tremens. At 
the autopsy, the following appearances were presented : There 
was a great efl"usion of blood into the tissues about the seat of 
injury. The head of the femur projected a short distance be- 
yond the edge of the great sacro-ischiatic notch, having fol- 
lowed the groove left by the displacement of a fractured portion 
of the acetabulum and bone behind. The latter was about an 
inch and a half square, and three-quarters of an inch in thick- 
ness at the thickest point. The fracture also extended through 
the acetabulum and the bone. The head of the femur was 
deeply indented, and the fragments of the bone and cartilage 
were separated. 

Case CCXXYI. — Dislocation of the Hip-joint hach- 
loards, and probably dowmoards. Reduction. — A little boy, 
six years of age, was sitting on a long heavy piece of timber, on 
March 18, 1860, when it rolled, throwing him down, and passed 
over him, bruising different parts of his body. When taken 
into the house, he seemed so much injured otherwise, that his 



382 EXTREMITIES. 

mother did not pay particular attention to the injury of the hip. 
On the third day after the accident, Dr. S. A. Green, being 
called in, detected a dislocation of the left hip, and advised his 
removal to the Hospital. 

When I first saw the boy, he was lying on the right side ; 
the left thigh being drawn up nearly at a right angle with the 
body, and placed rather across the opposite limb, as in some 
cases of hip-disease. On lifting him, and making him stand on 
the sound limb, at the same time drawing down the displaced 
one as far as it would go, the foot pointed forwards, instead 
of resting on the top of the other foot, as in dislocation on 
the dorsum ilii ; the pelvis was dragged down somewhat by the 
limb, and there was great tension of the muscles running from 
the femur to the pelvis, as is sometimes seen in dislocation 
into the foramen ovale, which it somewhat resembled in this 
respect ; but one of the principal signs of that dislocation, the 
depression of the trochanter, was wanting. The dislocation, in 
fact, resembled more what has usually been called the disloca- 
tion downwards and backwards, in which the head of the bone 
lies a little behind and below the socket. I took pains to try to 
obtain some measurements as to the difference in length of the 
two limbs ; but found this impracticable, in consequence of 
the bent position of the thigh on the pelvis. The head of the 
bone could not be felt, on account of the swelling which had 
taken place from the length of time since the displacement. 

The child being etherized, I first attempted to reduce the 
limb by the method of sweeping the thigh over the opposite 
limb and pelvis, producing a rotation of the bone. The limb 
was then seized by the ankle, gradually dragged down into a 
straight position, and then, by a slight rotation outwards, the 
head of the bone slipped, with a very distinct sound, into its 
socket. Motion could now be made of it easily and freely in 
every direction. 

Case CCXXVII. — Fracture of Upper Part of Thigh- 
hone, imitating Dislocation of the Hip-joint. — A powerful 
man, aged 40, a seaman, entered the Hospital, June 14, 1865, 
for an injury of th§ hip-joint, received seventeen months be- 



DISLOCATIONS. 383 

fore, which he supposed to be a dislocation. "He was guard- 
ing a government warehouse at Alexandria, Va., when he 
discovered three guerillas in the third story. He discharged his 
musket at one of them, killing him instantly; the second took 
to his heels ; a struggle then ensued between the patient and 
the third one, which ended in their grappling each other, and 
both rolling down a hatchway, landing on the ground-floor, a 
distance of some thirty-five feet, the guerilla underneath. The 
latter received two fractured legs, and a sentence of fifteen 
years in the Albany Penitentiary." The seaman was carried to 
a hospital, and etherized. He was afterwards informed, that 
his thigh was dislocated, but had been reduced ; and, at the end 
of six months, was discharged. His- leg, however, never as- 
sumed its original length, and he had the impression that the 
dislocation was never reduced. 

Upon examination, there was found shortening of one inch, 
but neither inversion nor e version. He could walk ; though, 
owing to the shortening and stiffness of the hip-joint, he carried 
a cane. There was an irregular projection (bony) behind the 
trochanter major. Patient was stout, robust, and in excellent 
health. Upon investigation, it was decided that the head of the 
thigh-bone was in its socket ; and that the shortening was due 
to a fracture received at the time of the fall, the precise nature 
of which could not be ascertained. He was again examined June 
21st, under the influence of ether, in the presence of all the vis- 
iting surgeons of the Hospital. It was decided that the head 
of the femur was in its proper position, and the shortening was 
the result of the old fracture. 

The stiffness of the limb, the projection behind the socket, 
and the want of history in regard to the fracture, at first led to 
the supposition that the patient's impression as to a dislocation 
existing might be a true one. Under ether, however, the mo- 
tion of every kind which could only be given to the head of a 
bone in its socket showed that the appearances were caused bv 
fracture, whatever the original injury had been, which possibly 
might, from the nature of the accident, have been both fracture 
and dislocation. 



384 EXTREMITIES. 

The following is a summary of the dislocations of the hip 
treated in the Massachusetts General Hospital, from Decem- 
ber, 1821, to May, 1866 : — 



Dislocation. Reduced. Not Reduced. 

Dorsum Ilii 22 

Ischiatic Notch 8 2 

Foramen Ovale 3 1 

33 



Total. 

25 

10 

4 



Of these, 38 occurred in males, and 1 in a female. In 19, the 
pulleys were used; in 20, no pulleys. Two of the unsuccessful 
cases were complicated with fracture. 



AMPUTATIONS. 

The question of points of election for the performance of am- 
putation has been re-opened within the past few years, and the 
rule of practice materially changed from that even now^ taught 
in some of the approved European text-books. The old rule of 
amputating the leg within a few inches of the knee — for an in- 
jury, perhaps, of the ankle — has given place, in this country at 
least, to the much safer, and in every respect better, practice of 
saving as much of the limb as possible. This reform is due 
almost wholly to the invention of the improved conical socket, 
now so universally employed in modern artificial limbs, in which 
the weight of the body is sustained by the accurate adjustment 
of the tapering sides of the stump to the corresponding cavity 
made to receive it, while the sensitive cicatrix is effectually re- 
lieved from pressure. 

The advantages of immediate amputation are perhaps now 
more fully recognized than ever before. Even during the pe- 
riod of depression or shock, where it would formerly have been 
thought necessary to wait for re-action, we now feel justified, in 
most cases, in proceeding at once to the operation ; having 
learned by experience, that the inhalation of ether is generally 
attended by a greater and more rapid restoration of the vital 
forces than that which follows the exhibition of alcoholic stimu- 
lants. By operating at this time, many patients may be saved, 
who would otherwise die from the gradual loss of blood, and 
from the nervous irritation dependent upon extensive injury. 



AMPUTATIONS . 385 

The kinds of operation which have generally been preferred 
in this vicinity are the circular for limbs with a single bone, and 
the flap for the fore-arm and leg. The operations of Syme and 
Pirogoff, for saving as much as possible of the lower extremity, 
and as substitutes for amputation in the leg, are well worthy 
of adoption in suitable cases. 

The operation by flaps of skin alone is now looked upon with 
great favor. I have often performed it with much satisfaction. 

One amputation — that at the hip-joint — may be particularly 
mentioned, on account of its striking want of success. Out of 
twenty-three operations mentioned by Macleod as having been 
performed in the Crimea, all proved fatal ; and, during the 
late war in this country, the successful cases were very few. 
It has been thought safer, therefore, to leave a man, with a 
compound comminuted fracture high up in the thigh, to the 
chances aflbrded by nature, rather than to perform the ampu- 
tation now under consideration. 

I have had an opportunity of twice performing this amputa- 
tion in Boston. One case was in a child whose limb was par- 
tially torn ofl* by a railroad accident ; the other was for a large 
tumor of the femur, which reached high up into the groin. The 
first patient died at the end of a fortnight, without evident 
cause, when apparently in a fair way of recovery ; the other 
recovered. The method adopted in the last case was by making 
anterior and posterior flaps of integument ; tying the femoral 
artery before making the section of the muscles. 

In cases of re-amputation for diseased stumps of the leg, and 
for tumors high up on the leg, where it is desirable not to go 
above the knee, I have had the following experience : — 

The flaps of skin being made, and the tibia and fibula sawn 
through just below their heads, the popliteal artery is apt to be 
cut ofl" at its division into the anterior and posterior tibial 
arteries. At the same time, the stump almost immediately is 
retracted by the muscles into the popliteal space ; and a trouble- 
some hemorrhage commences, which it is diflicult to arrest with 
the patient in his ordinary position on the back, and embarrass- 
ment is experienced in finding the vessels. Much blood also is 
usually lost, if the surgeon has trusted the vessel to digital com- 

49 



386 EXTEEMITIES. 

pression. During the spring of 1866, having had a number of 
these cases to deal with, I found great convenience in turning 
the patient at once over on his face, in which position the ves- 
sels were easily secured. In these cases, the simple flaps of 
skin have healed much more favorably than by the old method 
of muscular flaps, as recommended by Liston. For amputation 
of the thigh, Dr. John Green, formerly of Boston, now of St. 
Louis, in the June number of the Boston " Medical and Surs^ical 
Journal" for 1863, has given an excellent resume of the best 
methods now in use for making a good stump, which have been 
sustained by his experience in the army during the late war. 

On account of the danger of pyasmia in amputations at the 
present day, it has been proposed to operate at the joint, as less 
likely to be followed by this occurrence, than where the bone is 
divided in its continuity. 

Lisfranc's, Chopart's, Pirogofl^'s, and Syme's operations, I 
have had occasion to perform. In civil practice, however, the 
nature of the injury for which amputation is performed is such, 
that the opportunity for these operations is comparatively rare. 
They are peculiarly applicable to the lesions produced by fire- 
arms. 

Case CCXXVIII. — Amputation of the jLrm above the 
Elbow for Congenital Cancer of the Fore-arm. Death, after 
two years, from Internal Cancer. — A child, 11 months 
old, was brought to my surgical infirmary by its parents, on 
Sept. 9, 1843, having a large tumor involving the whole of the 
left fore-arm. At birth, the tumor was about tlie size of an Qgg, 
and regularly increased with the growth of the child. 

The mother was delicate, but none of the family had been 
affected with cancer. The child was, in other respects, appar- 
ently in fine health. The tumor evidently was carcinomatous. 
It was of a firm consistence, somewhat irregular in its outline, 
and in one part slightly discolored. Immediate amputation was 
advised. 

The parents did not bring the child again until the 7th of 
October, nearly a month afterwards. The tumor was then 
larger, and had softened at the discolored portion. Amputa- 
tion was performed above the elbow. 



AMPUTATIONS. 387 

The operation was borne well, and in a few weeks the child 
recovered perfectly. The tumor, being cut open, was found to 
be encephaloid cancer, softening having commenced in it. I did 
not hear from this child again until the month of June, 1845, 
when I was called to attend the autopsy ; he having died under 
the following circumstances. He had been in full health until 
three months before, when a physician was called to see him, 
and found him laborinof under a slisrht cono'h, and distress in 
the right side of the chest, which was slightly enlarged. The 
cough and pain gradually increased ; the chest and abdomen 
becoming enormously distended, as if from an internal tumor. 
He finally died in great suifering. 

The cavity of the thorax was occupied by an enormous mass 
of encephaloid disease, which had taken the place of the lung, 
some traces of which were found in the back part of the chest. 
The diseased mass forced the heart over to the left side ; it also 
projected through the crura of the diaphragm into the abdomen. 
The substance of the left lung was studded with encephaloid 
masses, some of wdiich hung, as it were, dependent from its 
surface. The heart was healthy. The liver, although not de- 
cidedly cancerous, was evidently much changed in structure. 
The kidneys, spleen, and other organs, were normal. The 
stump of the arm amputated was in a healthy condition, as well 
as the axilla of that side. The extremities of the nerves were 
much enlarged. 

Case CCXXIX. — Am23iitation at the Shoulder-joint, for 
Suppuration after a Burn, — A boy, four years of age, was 
brought into the Hospital in the middle of February, 1860, with 
his entire arm, part of his face, and chest, burned by the explo- 
sion of a burning-fluid lamp. The burn of the face and chest 
did well ; but almost the whole surface of the arm suppurated, 
and for a long time it was supposed the child must succumb, so 
profuse was the discharge. He was only kept alive by the use 
of large quantities of stimulants, taking from six to eight ounces 
of brandy in twenty-four hours. Finally, about the third week 
in ]\Iarcli, the arm began to have a gangrenous appearance, with 
patches in different parts, attended by hemorrhage from one of 



388 EXTREMITIES. 

them, which was arrested by the perchloride of h'on. He had 
also, at this time, hemorrhage from his nose. 

As soon as the child had rallied sufficiently, it was proposed 
to remove the arm, the stench from which was hardly support- 
able in the room. The parents, who were of the most ignorant 
and degraded sort, at first declined to have any thing done, but 
finally consented. The daily dressing of the wound caused the 
most violent outcries from the patient, on account of the exces- 
sive pain. 

The burn extended quite up to the shoulder ; and, with the 
exception of a small flap of skin behind, there was no integu- 
ment left to cover the wound. In removing the limb at the 
joint, the head of the bone was found to be so incorporated with 
the capsule, and attached to it, as well as so softened by disease, 
that the knife at first cut deeply into it. The vessels were im- 
mediately seized, compressed, and tied, so that very little blood 
was lost. A couple of sutures brought together the irregular 
edges of the wound. 

The irritation caused by the limb being removed, the patient's 
pulse rose at once. He almost immediately began to take 
food, recovered his appetite, and very soon his health. 

Some time afterwards, he was seized with attacks of uncon- 
sciousness, lasting at first for a short time, and ultimately died 
with cerebral symptoms. 

Case CCXXX. — Amputation at the 8hoidder-johit for 
Injurij. — An Irishman, 32 years of age, was brought to the 
Hospital on May 16, 1851 ; his arm having been drawn in, two 
hours before, between the cog-wheels of powerful machinery 
used for pressing hemp. The limb passed in up to the shoul- 
der. The bones of the hand were found to be crushed, the ra- 
dius and ulna not broken, the lower two-thirds of the humerus 
comminuted ; and an opening over the brachial artery, two 
inches below the axilla, allowed the finger to be passed in and 
up to the joint. The limb was removed by an anterior and pos- 
terior flap. Some difficulty was experienced in disarticulating 
the head of the humerus, from the fact, that, the bone being- 
broken below, no purchase could be had by which the head 



AMPUTATIONS. 389 

could be lifted from its socket. A powerful pair of forceps had 
been provided for this purpose ; but the displacement was ef- 
fected without having recourse to them. The patient did well. 

This was the first case of amputation at the shoulder-joint 
occurring at the Hospital. 

It will not be out of place to mention here a contrivance 
which I had subsequently arranged to replace in a degree the 
amputated arm. Finding how free and powerful the actions 
of the muscles were upon the scapula, I had a large solid leather 
cot or covering made to fit the stump. This was kept in place 
by two straps ; one passing over the opposite shoulder, the 
other and stronger one round under the opposite axilla. A 
strong hook was inserted in the end of the stump. With this 
appendage, the man assured me, that, after some months' prac- 
tice, he was able to do as good a day's work in sawing wood 
as he formerly could with the lost arm. 

Case CCXXXI. — Malignant Tumor of the Hight Arm, 
requiring Amputation at the Shoulder-joint. — This patient 
was a tall, thin man, 30 years of age. He had always been 
healthy until April, 1850, when he had discharges of blood 
from the kidneys, unattended with pain, continuing for one or 
two weeks. In June, the tumor appeared as a small hard lump 
under the skin of the arm, near the Insertion of the deltoid 
muscle. This gradually increased until it nearly encircled the 
arm, extending under, and raising up, the brachial artery and 
nerves. The motions of the limb were not much aiFected by its 
pressure until the winter of 1850-51, when it increased rapidly, 
and the active portion became somewhat painful. His physician 
considered the case a critical one, demanding the removal of 
the tumor or of the arm, and directed him to me. After a 
careful examination of the tumor, which was quite firm and 
movable, it was agreed that the patient should be etherized, 
the tumor cut into, and, if found to possess the characters of a 
malignant growth, that the arm should be removed at the 
shoulder-joint. 

The operation was done on the 15th of February, 1851 ; and, 
when the tumor was incised, it was found to be carcinomatous. 



390 EXTEEMITIES. 

The bleeding from it, which was quite free, was therefore 
stanched with a bit of sponge, and the removal of the arm pro- 
ceeded with. This was done by an anterior and a posterior 
flap ; the former being made from without inwards by means of 
a scalpel, in order to have a more regular wound, and the better 
to avoid impinging on the tumor. The subclavian artery, as it 
passes over the first rib, was so effectually compressed by Dr. 
H. W. Williams that scarcely any blood was lost. 

On Feb. 20th, he had a discharge of bloody urine, after a 
severe pain in the loins. He seemed to attach but little impor- 
tance to it ; and, in fact, it soon ceased. He rapidly recovered. 

The tumor had a lardaceous appearance, and, under the mi- 
croscope, showed fibrous tissue, in which, after much investiga- 
tion, cancer-cells were distinguished. 

Case CCXXXH. — J^ecrosis of Humerus, Amputation. 
— The patient was 21 years old. Three years before, after 
getting wet, he was seized with an inflammation in the vicinity 
of the elbow-joint, and suppuration ensued. After a time, bone 
was discharged. Other parts of the arm were subsequently 
attacked, and much bone removed. In the course of the dis- 
ease, the shoulder-joint and the elbow-joint became anchylosed ; 
leaving the hand fixed in strong rotation over the pubes, only a 
slio'ht lateral action being permitted by the movement of the 
scapula on the body. Very large sequestra still remained ; and, 
from the position of the hand and loss of use of the joints, it was 
thought, that, even if all the dead bone was removed, the limb 
would be left useless. Amputation was therefore decided on. 
Some difficulty was experienced in fixing on the point for re- 
moval. If the section was made above the apertures in the 
head of the humerus, it would be difficult to get a flap from the 
inside on account of the size of the new bone, which was forced 
close upon the ribs, obliterating, as it were, the axilla. On 
consultation, it was decided to amputate a few inches below the 
shoulder, removing the sequestrum afterwards. This was done, 
and a large piece of dead bone forcibly extracted. The axillary 
artery, from the confined position of the wound, was secured 
with some difficulty, as had been apprehended. 



AMPUTATIONS. 391 

The patient left the Hospital about four weeks after the opera- 
tion, much improved in health, with the wound in a healthy con- 
dition. 

Case CCXXXIII. — 8yme^s Operation on a Girl affected 
with Talipes Varus and Spina Bifida. — A girl, 13 years 
old, entered the Hospital, April 13, 1860, on account of con- 
genital talipes varus of the left foot, with ulceration below the 
ankle, which had existed for six years. 

She had also a spina bifida over the sacrum, about four 
inches in diameter. It was fluctuating, elastic, and painful 
under strong pressure. She had incontinence of urine, and, at 
times, of feces. Her mental faculties were impaired. There 
was a fetid discharge from the ulcer, and dead bone could be 
felt with a probe. 

April 21st. Syme's operation was performed at the ankle- 
joint. There was more than usual suppuration in the wound ; 
and, May 4th, free hemorrhage occurred, which was stopped 
with difficulty. Subsequently, she did well, and was dis- 
charged May 26th. 

The disease in this case appears to have arisen from impaired 
nervous energy, probably owing to the tumor implicating the 
spinal cord. 

Case CCXXXIY. — Amputation for Caries of the Bones 
of the Foot. Double Talipes Varus. Spina Bifida. — A 
young lady, 17 years of age, applied to me for advice in April, 
1849. She had a spina bifida over the last lumbar vertebra, 
which in infancy was about the size of a bean. At the time 
I saw her, it was divided by a deep sulcus, one side directly 
over the spine ; being about as large as a medium-sized apple, 
soft and fluctuating, and protected by a thick, tough skin. The 
other side, about half as large as the first, bulged out on the 
right, and was solid. This tumor gave rise to no abnormal 
sensations ; nor did it interfere with the motion of the lower 
extremities, unless when injured by a blow, when it was followed 
by temporary numbness. 

Soon after she began to walk, talipes varus of the left foot 



392 EXTREMITIES. 

appeared ; and so great was the deformity, that she rested en- 
tirely upon the outside of the foot. The friction and pressure 
gave rise to an ulcer, which resisted treatment, and gradually 
extended over the whole of the side of the foot. From time to 
time, portions of bone had been discharged, and finally the little 
toe separated in a gangrenous condition. Necrosed bone could 
still be detected through three fistulous openings in the ulcer. 
After a long attack of sickness in her eighth year, the right foot 
became deformed in a similar manner to the left. 

The left leg was one and a half inches shorter than the right, 
the knee two and a half inches lars^er round. The shortenins: 
was caused by the loss of portions of the fibula and tibia, which 
were discharged through fistulas whose cicatrices remained. 
There was an abscess over the external malleolus on the outside 
of the right foot. 

April 7th. She was etherized, and the left foot amputated, 
just above the ankle, by the lateral-flap method. The edges of 
the wound were brought together by a single suture and adhe- 
sive plaster. She did well ; the wound uniting partly by first 
intention, and partly by granulation. 

May 4th. The tendon of the tibialis anticus and the tendo 
Achillis of the right leg were divided ; and, a few days subse- 
quently, an apparatus was applied to straighten the foot. 

June 30th. She could rest her weight upon the sole of her 
right foot, though it was not entirely straightened, and was 
still weak. She afterwards had an artificial foot for the left leg, 
which restored completely the power of walking. 

Case CCXXXV. — Plrogoff^ s Amputation at Anlcle-joint 
for Railroad Accident. Sloughing . Re-amputation. Re- 
covery. — A young man, about 20 years old, was brought into 
the Hospital on the 23d of June, 1865, with his foot crushed ; 
having, the night before, stepped upon the top of an engine 
while in motion, catching his foot in the machinery. The 
phalanges and metatarsal bones were comminuted, the integu- 
ment covering them destroyed, and the skin torn upwards over 
the astragalus. He insisted that nothing should be removed that 
was not absolutely crushed, though I informed him of the dan- 



AMPUTATIONS. 393 

ger of sloughing of the soft parts in accidents of this description 
in which vitality did not appear destroyed at the time. It was 
decided, therefore, to perform Pirogoif's operation. 

An incision was made in front of the internal malleolus, 
carried under the foot, and terminated near the external mal- 
leolus. The integuments of the heel were then dissected a 
little from the bones, and the incision carried across the 
foot in front, so as to expose the joint. The astragalus was 
disarticulated; and, in dissecting it out, in order to get at the 
OS calcis, care was taken not to injure the posterior tibial artery. 
The OS calcis was then sawn through obliquely, and the foot 
removed. The integuments of the lower part of the leg covering 
the joint were dissected back a little ; and the external and in- 
ternal malleoli, together with the articular surface of the tibia, 
were removed with a saw. This was done with some difficul- 
ty, owing to the primary incisions having been made in front 
of the malleoli, as described in the books ; whereas it would 
have been much better to have begun farther back, which 
could have been easily done without endangering the vessels 
that supply the flap. It being found that the os calcis inter- 
fered somewhat with the easy approximation of the lips of the 
wound, a slice was removed from it. The ends of two or three 
tendons which projected were cut off" with scissors, as was also 
about an inch of the plantar nerve. The bone came well into 
place, and the edges of the wound were approximated by a 
large number of sutures. A broad strip of adhesive plaster 
was applied so as to keep the bone steady, over this a towel 
folded lengthwise, and the whole secured in a hollow padded 
splint to counteract any retraction of the muscles of the calf. 
He was ordered a large opiate at night, and slept quite well. 
The next day he complained of pain from the pressure of the 
splint, which was then removed. 

On the 25th of June, the weather being very hot and the 
smell of the dressings quite offensive, they were removed, with 
the exception of the adhesive plaster ; and a compress, wet 
with a weak solution of the permanganate of potash, was applied. 
Very shortly, as I had feared, a slougli commenced in the centre 
of the wound; and, as it separated, repeated hemorrhages took 

50 



394 EXTEEMITIES. 

place, finally followed by gangrene and erysipelas of the lower 
part of the stump. It being impossible to amputate the limb in 
that condition, the flaps were separated, and the bleeding vessels 
found and tied. The limb subsequently required amputation 
higher up, which was done some weeks afterwards, by one of 
my colleagues (my service having expired), when the patient 
was in a proper condition to support it ; and he did well. 

The operation of PirogofF at first gave every indication of 
success ; but, as we are continually observing in railroad acci- 
dents, the injury to the muscles, vessels, and nerves, was much 
more extensive than would at first be supposed, and necessitated 
the subsequent amputation of the leg. 

Case CCXXXVI. — Re-ampiUation of Leg. Recovery. 
— March 22, 1866, a man 48 years old entered the Hospital for 
painful stump of right leg : twenty-eight years before, when at 
sea, whaling, his right foot was torn oif at the ankle, by being 
caught in a coil of rope which was " running out " with great 
rapidity. A few days after the injury, the leg was amputated 
just above the ankle. The patient stated that no flaps were 
made, but that the limb was cut " square oflT." The stump was 
long in healing, and afterwards there was much pain of a neu- 
ralgic character in it. For the three months previous to his 
coming to the Hospital, he suffered from an indolent ulcer on 
the end of the stump. 

March 24th. The patient being etherized, re-amputation 
was performed, by flaps ; a long anterior and short posterior 
one, chiefly of skin, being taken. There was much venous 
oozing after the vessels were tied, which, however, subsided 
after the stump had been exposed to the air for two hours. The 
flaps were then brought together with seven sutures, and cold 
water-dressings applied with a moderately firm bandage. On 
examination of the amputated portion, the posterior tibial nerve 
was found to be bulbous at its extremity ; and from it numerous 
nervous filaments were distributed to the end of the bone. The 
flaps united almost by first intention, and in three weeks the 
patient was discharged well. 



AMPUTATIONS. 395 

Case CCXXXYII. — Amputation of Leg, high up, loith 
Cutaneous Flaps. — April 6, 1866, a man aged 46 entered 
the Hospital with a large ulcer of a cancerous appearance en- 
tirely encircling the lower part of the right leg. Its edges were 
callous and elevated. It began three years before, and he had 
done no work since. The last six months, he had been unable 
to walk on the leg, which was bent to a right angle wdth the 
thigh. 

Amputation being decided upon, the question was, at what 
point this should be done. There was integument enough for 
a long stump ; but this was objectionable on account of the 
flexed position of the knee. It was therefore determined to 
divide the bones just below the head of the tibia, as making a 
better stump than the condyles of the femur by the knee-joint 
operation. 

The popliteal artery, being divided just after its bifurcation, 
retracted, and the stump, at the same time, was powerfully 
drawn backwards by the flexor muscles still attached to it. 
This state of things rendered it very difficult to get at the ves- 
sels ; but, by turning the patient on his face and dissecting up 
the tissues, they were finally reached and tied. 

In the present instance, two flaps were made of skin alone, 
instead of employing Liston's method, the division of the mus- 
cles being made by a circular cut. The two arteries, lying in 
contact just after the division, w^ere now easily seen, and tied at 
the back of the wound. 

This amputation, with two flaps of skin and a circular cut in 
the muscles, is the most satisfactory one, in this situation, that 
I have ever done. An amputation, lower down, performed 
recently in the same way, has also resulted better than usual. 

The ulcer, on microscopic examination, proved to be epithe- 
lial cancer. The bones, though perhaps a little enlarged, were 
not implicated in the disease. The patient did remarkably well, 
the flaps healing almost by the first intention. 

Case CCXXXYIIL — Amputation of the Thigh at the 
Lower Third, for Disease of the Knee-joint of eighteen 
years^ standing. — The following case of disease of the knee- 



396 EXTREMITIES. 

joint is one of those so frequently met with, more particularly 
in women, where the patient is kept under treatment for many 
years, with alternate improvement and relapses ; the disease 
ultimately requiring an operation. On inspection of the joint, 
the surgeon is surprised at the great extent of disease, and 
that the operation has been so long deferred. 

A woman, 42 years of age, much emaciated, and of a very 
livid complexion, came under my care in the Hospital, in 
April, 1865. Eighteen years before, she had fallen down stairs, 
striking upon the right knee, which became swollen, and con- 
fined her to her bed for five or six weeks. Since then, she had 
scarcely ever passed a year without having an attack of inflam- 
mation in the joint, confining her to the house. In April, 1864, 
it became more inflamed than usual ; and an abscess formed, 
which pointed in the popliteal space. 

The limb was somewhat flexed, and the tibia slightly dislo- 
cated backwards upon the femur, and the patella apparently 
fixed to the outer condyle. The husband of the patient wished 
her, as she said, to submit to treatment for several months 
more before having any operation performed ; but she preferred 
to wait no longer. The question of excision was considered, 
but not urged, on account of the state of her general health; 
and she decided the matter by declaring for an amputation. 
This was done by the circular method, with the loss of but a 
few drops of blood ; compression being made by a tourniquet 
invented by John Whitton, the ingenious ward-tender at the 
Hospital, which compressed the artery only, without interfering 
with the venous circulation. The wound was closed with two 
sutures ; and the only dressing used was a compress, wet with a 
weak solution of permanganate of potash, with the view of pre- 
venting infection of the wound by Hospital gangrene, which 
was prevalent at the time. The shock of the operation pro- 
duced considerable exhaustion ; but, by the use of stimulants 
for several hours, she recovered from her depressed condition. 

The case terminated favorably in a few weeks. 

An examination of the joint showed the tibia displaced back- 
wards upon the condyles of the femur, the cartilages completely 
destroyed, and the epiphyses of the bones extensively carious, 



AMPUTATIONS. 397 

and in a crumbling condition. The cavity of the joint opened 
externally by an irregular fistulous canal, which terminated in 
the popliteal space ; and the patella was firmly fixed to the outer 
condyle of the femur. 

Case CCXXXIX. — Compound Fracture into the Knee- 
joint. Great Depression. Amputation of Thigh. — 1852. 
This man was first seen by me at 6, p.m., having received a 
compound comminuted fracture of the knee-joint an hour and 
a half before, from the fluke of an anchor falling upon him. A 
wound existed on each side of the joint, so that the finger could 
be passed from one side to the other, encountering the broken 
fragments of bone. The injured part was quite insensible to 
the examination. There was a moderate but constant flow of 
blood from the wounds. The pulse was 120, irregular, feeble ; 
patient a little flighty. Stimulants were given every fifteen 
minutes for two hours, but with no improvement in the pulse; 
the discharge of blood gradually increasing from the wounds. 
Under these circumstances, the question w^hich presented itself 
was, whether to proceed to immediate amputation, from fear of 
the patient losing his chance by hemorrhage, or to apply a tour- 
niquet, and wait for an improvement in the symptoms. 

On consultation with my colleagues at the Hospital, the latter 
course was decided upon. On the following morning, the ap- 
pearances were much the same ; pulse 120. The leaking of 
venous blood continued. On further consultation, it was 
thought unsafe to defer longer the removal of the injured part. 
He was therefore etherized, and the amputation performed. 
The case terminated favorably. Generally speaking, cases of 
this description have done well after immediate amputation, 
since the introduction of ether. The want of vitality in the 
present case, how.ever, seemed hardly to justify it, even with 
the assistance of this agent. 

Case CCXL. — Amputation of Thigh for N'ecrosis. — 
Mr. F., 28 years of age, applied to me in February, 1864, on 
account of a necrosis of the femur, for which he requested to 
have an amputation performed. When he was fifteen years old. 



398 EXTREMITIES. 

he received a shock in the limb by jumping from a wall, which 
was followed by severe inflammation, ending in abscess, which 
opened at the lower and inner part of the thigh, just above 
the knee. In the course of a year, abscesses formed along the 
whole length of the limb, communicating with the bone, some 
in front, and some on the outer side, as high as the trochanter 
major ; through these apertures, small pieces of bone were 
occasionally discharged. In the first year, while bearing some 
weight on the leg, the femur gave way in its lower third, but 
united again, with shortening of three or four inches, and with 
a decided bend outwards. From 1856 to 1864, he suffered 
much at the original site of the disease ; the inflammation 
extending to the knee-joint, which became nearly stiff". For 
nearly half of this period of thirteen years, he was confined by 
successive attacks of inflammation ; and he finally decided to 
submit to an operation, when he saw that his future usefulness 
and comfort were likely to be altogether destroyed. A consul- 
tation was held upon the case at the Hospital, which resulted in 
the decision to remove the limb at the level of the his^hest fistu- 
lous opening, which was at the commencement of the upper 
third of the femur ; and, in case the sequestrum should be 
found to extend higher, to attempt its forcible extraction by 
means of forceps, which I had before successfully accomplished 
in a similar case, where it was important to preserve as long a 
stump as possible. The exact amount of bone diseased could 
not be accurately determined, owing to the severe pain and pro- 
tracted constitutional disturbance which had several times fol- 
lowed the attempt to probe the lower openings in the popliteal 
region, and which was explained on dissection by the proximity 
of the sequestrum to the great ischiatic nerve. 

The operation was performed Feb. 27th. A flap was first cut 
out on the front and outer side of the thigh, having its base at 
the upper aperture already described, which was placed rather 
on its inner aspect. An inner and posterior flap was then made, 
and the bone sawed oflp just above the point of junction of the 
flaps, which proved to be in the sound bone, three-quarters of 
an inch above the upper extremity of the sequestrum. This 
was about four inches long, and lay loosely encased in a cavity 



AMPUTATIONS. 399 

in the back and lower portion of the femur, which was open for 
the most part, but was crossed, at about the middle of its length, 
by a bridge of new bone of about half an inch in breadth. The 
nerve, as above stated, lay directly on it. The sequestrum was 
so loose that it could have been entirely removed, if it had been 
possible to reach it by any justifiable operation. The knee-joint 
had been partially disorganized by inflammation ; two small sur- 
faces, however, remaining on the condyles, still covered by car- 
tilage, each about half an inch in diameter, and corresponding 
to the articulating surfaces of the tibia, Avhich were concerned 
in the slight motion remaining. On the curved portion of the 
bone, in front and opposite to the sequestrum, were marks of 
the very oblique fracture which had taken place during the first 
year of the disease. The specimen is now in the Warren Ana- 
tomical Museum. 

In speaking of this case, I would remark, that I have seen 
very few cases of extensive necrosis of the femur which have 
been relieved by operation. The records of the Massachusetts 
General Hospital show the same fact. In one case, I removed 
half of the shaft, near its lower extremity, with perfect relief; 
in another case, of twenty years' duration, which was one of 
necrosis of the whole length of the shaft of the bone, the opera- 
tion was followed by so long and exhausting a suppuration as 
to compel the amputation of the limb just below the trochan- 
ters, to save the patient's life. This man afterwards died of 
an extensive cancer of the stump. In the present instance, 
even if the removal of the dead bone had been practicable, the 
patient would have been left with a deformed limb, three or 
four inches shorter than its fellow, and with little or no useful 
motion of the knee-joint. 

In this case, as is usual where there has been much previous 
inflammation in the amputated limb, the hemorrhage from the 
smaller vessels was very abundant. 

The convalescence was slow, and interrupted by a series of 
abscesses in the stump. Although no exfoliation of bone took 
place, it was several months before tlie patient was well enough 
to return to his home in the country, but with his stump only 
partially healed. In October, 1864, I saw him in fine liealth 



400 EXTREMITIES. 

and high spirits, his stump entirely healed, and having gained 
thirty or forty pounds of flesh. This increase in weight, as is 
well known, is not unusual in persons who have submitted to 
amputation after having gone through with a long suppuration 
from a diseased limb. 

Two years afterwards, he was seen, quite well, and still in- 
creasing in weight. His figure, instead of being distorted, as 
before the operation, was erect ; and he walked well with a 
Palmer leg. 

Case CCXLI. — Amputation of Thigh for Anchylosis of 
Knee-joint. Necrosis of Tibia, and other Disease. — May 3, 
1866, a young man of rather weak and sickly appearance, 20 
years of age, entered the Hospital for an amputation of the 
thigh. Three years before, he fell, striking his left knee, pro- 
ducing a swelling and inflammation of the knee and leg which 
confined him to his bed twenty-two months. A year after, a 
large portion of the front of the tibia, in a necrosed state, was 
removed. 

On investigation, I found the affected knee larger than the 
other, stiff and painful. Above it were the cicatrices of two 
ulcers ; below, a depression, marking the position where the 
bone had been removed. Close to this, a sinus existed, running 
upwards and outwards to the inner condyle of the femur, where 
dead bone could be felt. The foot was inverted, presenting the 
appearance seen in talipes varus, which, the patient said, took 
place when he attempted to walk after the operation for necro- 
sis. There was not only inversion, but extension to such a 
degree as to give the appearance of talipes equinus : the leg was 
shortened four inches. The limb, being entirely useless, was 
amputated. May 5th, with an anterior flap of skin ; a circular 
cut beino^ made behind, so as to brino; the cicatrix on the back 
part of the stump. 

The patient did pretty well until May 31st, although there 
was some suppuration in the stump and retraction of the flaps, 
when an abscess formed on his left hip, which was relieved by 
an incision. In this, as in some other cases, where a retraction 
of the flaps occurred from suppuration in the stump, a very 



AlVIPUTATIONS. 401 

rapid cicatrization took place, from extension made on the in- 
teguments with adhesive plaster and a weight. On the 19th of 
June, he was well enough to go home. 

The following is the description of the amputated portion : 
The tibia and fibula were dislocated on the back part of the 
femur, and anchylosed to it and to each other ; the patella was 
anchylosed to the external condyle. On the front part of the 
tibia, a long and deep sulcus existed, from which had been re- 
moved a sequestrum of the whole calibre of the bone, nine 
inches long, which the patient carried with him. The foot was 
in a complete state of extension, combined with slight e version, 
so as to form an almost continuous line with the tibia, and in a 
state of false anchylosis. 

Case CCXLII. — AmjnUafioii of both Thighs, for RaiU 
road Injury. Death twenty-three days after. — On June 2, 
1864, a man w^as brought into the Hospital, who, two hours 
before, was thrown from the railroad track by the engine. He 
sustained a compound comminuted fracture of both bones of 
each leg, with deep ragged wounds near the ankles. When 
brought in, he was almost in a state of collapse, having lost 
much blood. Stimulants were freely given, which were fol- 
lowed by some re-action. He was etherized, and both legs 
amputated just above the knee-joint by the circular method. 
But little blood was lost during the operation. Four vessels 
required ligatures in the left, and three in the right stump. 
The patient was so depressed during the operation, that it was 
necessary several times to suspend the use of the ether, in order 
to ascertain his exact condition. He rallied, however, from the 
operation well ; and, being put on a nourishing diet with suffi- 
cient stimulant, improved until the 17th, when he had a severe 
chill, followed in a day or two by sloughing of the integuments 
covering the ends of the stumps. From this time he gradually 
sank, and on the night of the 25th died. 

Nature seemed to have made a great effort, in this case, to 
sustain itself against the great shock of the injury, and also to 
repair it. But in spite of all the natural efforts, assisted in every 
way by art, it was unable to accomplish the process. For two 

51 



402 EXTEEMITIES. 

weeks, he promised as well as any case after a simple operation. 
He was then seized with a chill, as stated above, and slowly 
sank. 

Case CCXLIII. — Amputation at the Hip-joint for a 
large Osteo-sarco7natous Tumor of the Femur. Recovery. — 
A young man, 16 years old, of very light complexion and 
reddish hair, entered the Hospital, March, 1859. He was born 
in Maine, of healthy parents, and, so far as was known, with 
no scrofula in the family. His employment for a year had been 
that of shoemaking. About seven months before he entered the 
Hospital, at the upper and front part of the thigh a deep-seated 
tumor made its appearance, immovable and slightly painful. It 
increased slowly in every direction, until he was brought to 
the Hospital in the last week of March, 1859. At this pe- 
riod, the left femur, which was the seat of the disease, was 
slightly flexed on the pelvis ; and the upper half of it was occu- 
pied by a large, firm tumor, making a very distinct projection 
in front, but more indefinite behind, where it mounted up, and 
was lost in the nates. The front part of it was somewhat 
nodulated, and was in immediate contact with, and partially 
pressed up, Poupart's ligament. The skin was everywhere 
movable on the surface of the tumor, except on the outer side, 
where a slight redness existed, caused by the application of a 
blister. There was a moderate degree of mobility of the joint, 
sufficient to show that the articulation had not been invaded by 
the disease. The patient could use the limb a little, and was 
able to walk out with support, though very lame. The glandu- 
lar system generally was Intact. The appetite was poor. He 
had no fever. The pain in the tumor required the use of an 
opiate at night. The circumference of the limb over the tumor 
was twenty -two inches ; the measurement of the corresponding 
part of the opposite thigh, fifteen inches. 

Having made an examination of his case, I told the brother 
of the patient, that all applications were useless, and the only 
remedy left was amputation at the hip-joint. The case being so 
important, on the following day I called a consultation of the 
surgeons of the Hospital, which resulted in the following con- 



AMPUTATIONS. 403 

elusions : That the disease was probably an osteo-sarcomatous 
affection of the femur, which, if left to itself, would very shortly 
terminate the patient's life in a most painful manner ; and the 
only thing to be thought of was the removal of the femur 
at its articulation with the hip-bone. On the other hand, 
from the size and situation of the tumor, that the operation 
was an exceedingly hazardous one, more so than in the ordinary 
cases of its performance ; that there was a possibility of his 
dying during the operation, or within the subsequent ten days ; 
and, even if he recovered from the immediate shock, that there 
might be a re-appearance of the disease ; that these conditions 
being properly placed before the patient and his friends, if they 
concluded to take the risk, the operation ought to be done. 
This question having been fully weighed by the patient and his 
brother, they decided to have the limb removed, rather than 
run the risk of submittino; to the lino-erino^ course of the disease. 
The operation was performed in the following manner, on 
Monday, March 28th, the fifth day after his entrance into the 
Hospital. The ordinary method by transfixion being impracti- 
cable, and in view of the possibility of a dissection of the tumor 
from its attachments, a large flap of skin was raised from its 
front part ; the incision commencing at the root of the scrotum, 
and terminating just above, and in front of the great trochan- 
ter. The flap was dissected up quite to Poupart's ligament, the 
fascia over the femoral artery opened, the vessel exposed, a liga- 
ture passed around it and tied. An incision was then made on 
the back part of the thigh, corresponding with that in front, 
and a flap of skin partially raised. With a short, strong knife, 
the muscles running from the pubes to the inside of the tumor 
were cut through, and those on the outside treated in a similar 
manner. These incisions loosened the thigh, which had before 
been confined, and allowed it to be depressed and rotated out- 
ward. It was necessary to do this to a great extent, on account 
of a lobe of the tumor projecting over and obscuring the articu- 
lation. The knife was next applied to the capsule, which was 
divided, the round ligament snapping off at the same time from 
the powerful force applied to it. The bone was then disarticu- 
lated, the great muscles of the thigh cut through behind, and 



404 EXTREMITIES. 

the limb removed. A very large sponge was thrust into the 
wound, to prevent bleeding, while the smaller vessels in the flap 
and trunk were secured. By the skilful compression of the 
abdominal aorta by Dr. Gay, the immediate seizure and com- 
pression of the flaps by Dr. Cabot, together with the previous 
ligature of the femoral, scarcely any blood was lost. The ves- 
sels in the flaps were successively tied as they were uncovered 
by the removal of the sponge : it was also found necessary to 
secure the great femoral vein. 

The lips of the wound were brought together by a number of 
sutures ; a compress was applied, and a very large sponge, to 
make gentle compression, and fill up the deep cavity in the side 
of the pelvis ; over this a towel, and the whole firmly secured 
by a bandage. The operation was necessarily protracted much 
beyond the usual time of an ordinary disarticulation ; yet after 
its termination, and just before the removal of the patient from 
the table, his pulse was as good as before the operation was 
commenced. 

A section made of the tumor and the femur, which were 
sawn longitudinally through the middle, presented the following 
appearances : The tumor was beautifully variegated, and pre- 
sented the ordinary aspect of osteo-sarcoma. It had its origin 
between the periosteum and the bone, and extended from the 
middle of the femur quite to its neck. The periosteum cover- 
ing the greater trochanter had been peeled up, and the sac of it 
filled with that yellow oleaginous fluid which is so frequently 
seen in tumors connected with the bone. The parietes of the 
bone were somewhat thickened in the centre, thinned toward 
either extremity, and the medullary cavity was almost oblit- 
erated. The substance of the tumor itself was quite firm, hav- 
ing the ordinary appearances of carcinoma interspersed with 
spiculge of bone. A microscopic examination of it was made by 
Dr. Ellis, and verified the diagnosis. The head and neck of 
the bone seemed to have completely escaped invasion. The 
muscles covering the tumor were partially adherent to it, but 
none of them so completely incorporated with it as at first had 
been feared. The tumor seemed to have been entirely enucle- 
ated ; and, so far as could be ascertained, not the slightest trace 
of it was left behind. 



AlVIPUTATIONS. 405 

In the afternoon of the day of the operation, the patient 
seemed to be in a good condition, and complained only of the 
tightness of the bandage around his body. This was loosened 
by cutting it away partially, and completely removed on the 
following morning. He passed a pretty good night, under 
the effect of a drachm of the solution of the sulphate of mor- 
phia, complaining principally of an excessive thirst, which no 
amount of drink seemed to satisfy, and which I attributed partly 
to the ether. On j\Iarch 30th, the thirst was somewhat alle- 
viated, but he was still without appetite, and complained of a 
little soreness in the groin ; pressure gave pain in the lower 
part of the abdomen. The pulse was 100. 

The following day he took an enema, which emptied his 
bowels, and seemed to improve his appetite, so that he chewed 
a little beef; also took brandy and water and milk punch, to 
which he was much averse, never having taken spirit in his 
life. 

On Saturday, April 2d, the wound began to be rather offen- 
sive ; and at the suggestion of the venerable and distinguished 
Professor Mussey, who was present, the dressings were removed, 
and a yeast poultice applied : the pulse was rather over 100 ; 
the appetite still doubtful. On Monday, the 4th, his pulse 
was 120 ; there was profuse sweating while sleeping ; he began 
to take his food more regularly, and his pulse to have considera- 
ble firmness. He was allowed bread, tea, and baked apple for 
breakfast ; bread, meat, and baked apple, of which he was very 
fond, vegetables, with brandy and water, for dinner; for sup- 
per, the same as at breakfast ; at bedtime, and to drink through 
the night, from half a pint to a pint of milk-punch. On the 8th 
of April, he was reported as doing well : "He makes no com- 
plaint, the pulse is about 100, and he may be said to be in a 
convalescent condition ; the bowels are emptied every other day 
by enemata, and he has taken no purgative medicine since the 
day of the operation." 

The patient went on improving till the third week after the 
operation. The wound healed well, leaving an aperture at 
either end for the escape of ligatures. About the twenty -fourth 
day, on waking in the morning, he felt a pressure at the inner 



406 EXTREMITIES. 

part of the stump ; and, shortly after, a stream of blood slowly 
trickled down. Dr. Ezra Dyer, the house-surgeon of the Hos- 
pital, was immediately summoned, and by means of a sponge 
applied over the apertures from which the ligatures issued, and 
a strong compressing bandage, succeeded in arresting the bleed- 
ing. The bleeding recurred again in about two hours, and was 
arrested in the same way. When I saw the patient, at 9, 
A.M., he was rather pale, his pulse rapid, and his system had 
evidently received a severe shock. He was not much alarmed : 
but, on this and the following day, made great complaint of ex- 
cessive thirst, as he did after the operation : showing that it was 
the loss of blood, and not the ether, which previously caused this 
symptom. From the free escape of blood at the time, and its 
arterial color, it was thought probable to have escaped from the 
great vessel, in consequence of the ligature having partially de- 
tached itself; and for this reason it was deemed prudent not to 
interfere with the wound for the next two or three days. No 
new bleedino^ havins: occurred, I then had all the dressing's re- 
moved. The two ligatures at the outer part of the stump were 
seized by the fingers, and withdrawn with very slight force. The 
four ligatures at the internal part of the stump were then sep- 
arated, and dragged upon singly ; and all of them were removed 
without difficulty. The two large ones, which had been attached 
to the femoral artery and vein, had probably been for some time 
detached, and lay coiled up in the wound, causing irritation and 
suppuration, and probably the hemorrhage which had given the 
alarm. 

From that time the wound rapidly healed. The patient left 
his bed in about a week, and in ten days was able to go out of 
doors. May 10th, he returned home quite well. 

Remarks. — This case is worthy of notice from having been 
the first of amputation at the hip-joint that has succeeded in 
Boston. The following statistics, from Mr. Erichsen, in his 
valuable work on Surgery, may be interesting, as showing its 
mortality : Of 126 cases, 76 died ; of 47 cases in which it was 
done for injuries, 35 died ; of 12 cases operated on in the Crimea, 
all died. During the late American war, as nearly as I can 
learn, there were 23 cases of amputation at the hip-joint, of 



AMPUTATIONS. 407 

which 5 recovered, and 18 died. Of these, 10 were primary 
operations for gunshot wounds, of which 3 recovered, and 7 
died ; and 13 secondary operations for the same cause, of 
which 2 recovered, and 11 died. 

The flaps in this case, being principally composed of skin, 
made the wound much less appalling and more manageable than 
where large muscular flaps are left, as in the ordinary operation. 
This may be considered worthy of imitation, even when not re- 
quired by necessity, as in the present case. The previous tying 
of the artery, together with the compression of the aorta, 
allowed the operation to be performed in a perfectly comfortable 
manner, without the slightest hurry, and with almost a dry 
wound, if the expression may be used. 

This patient lived for some months in very good health ; but 
the disease returned internally, and he died within a year of the 
operation. 

Case CCXLIY. — AmpiUatio^i at the Hip-joint, Death 
thirteen days after. — A child, six years old, was brought 
to the Hospital on the 19th of June, 1858, at three o'clock, 
having been injured about two hours before. He was sitting on 
the curbstone of the sidewalk, when a truck wheeled round 
against him, crushing his limb against the stones. His injury 
at first was not detected : being lifted up by some passer-by, and 
placed upon his feet, not being able to support himself, he fell, 
and received, in addition to his other injuries, a violent blow 
upon the forehead. When brought to the Hospital, his state 
was as follows : He was quite faint, countenance livid, pulse 
small. The integuments of the thigh, near the hip, were nearly 
cut through by a semicircular wound ; and on the outside a 
deep wound in the muscles communicated with the bone, which 
was fractured obliquely, and denuded nearly up to the joint. 
As the blood was flowing from this extensive wound, the case 
admitted of no delay ; and amputation was at once performed. 
The boy was first stimulated with as much spirit as he could 
bear, and ether was administered, which quickly brought up the 
circulation. The limb was then separated at the fractured part, 
Dr. Shaw compressing the artery. Dissection was next made 



408 EXTREMITIES. 

at the side of the bone, which was disarticulated with difficulty, 
both from the anatomical relation of the parts, these being 
obscured by ragged muscles, and more especially from the 
remaining portion of the femur being too short to be easily con- 
trolled in effecting the disarticulation. The capsule was, how- 
ever, opened, and the bone dissected out with but little delay. 
The boy at this moment became deadly faint, and was only 
restored by using frictions of brandy and ammonia ; the latter 
being applied also to the nostrils. He was likewise suspended 
by the remaining leg so as to throw the blood to the brain ; and, 
under this treatment, soon revived, although at one moment he 
seemed to be dead. The vessels were now tied, and the wound 
temporarily dressed. Just as this was finished, he a second 
time came in peril of his life. As is often the case with patients 
recovering from ether, he seemed disposed to vomit ; and, in fact, 
a basin was held, and he threw up a large quantity of liquid 
substance. Immediately after this, he fell back as if exhausted, 
a cold sweat came over him, and the respiration and pulse 
ceased. The frictions, and other means for restoring suspended 
animation, were at once again resorted to ; and I proceeded to 
pass the finger into the mouth for the purpose of raising the 
epiglottis and making a passage for the air into the windpipe, 
when it encountered a mass of solid potato-like substance, with 
which, on further investigation, the whole mouth and fauces 
were found completely blocked, so as entirely to exclude the air, 
and almost suffocate the patient. The teeth had allowed the 
liquid contents of the stomach to pass between them, but had 
acted as a strainer to retain the solid matters in the mouth. 
The mouth being now cleared, and artificial respiration set up, 
the child gradually commenced to breathe, and, in the course of 
half an hour, was in a safe state. At 9, p.m., the limb was 
dressed, and he was taken to his bed in the ward. The patient 
lived thirteen days, and received during this time the most un- 
remitting care from the nurse in charge of him, and from Dr. 
Dyer, the house-surgeon of the Hospital. The stump, during 
this time, became quite sloughy ; and one or two abscesses formed 
in the groin. The whole wound, however, finally assumed a 
healthy appearance ; and, when there seemed to be every pros- 



EXCISION OF JOINTS. 



409 



pect of his having gone safely through the most dangerous part 
of the trial, he suddenly failed and died, nearly a fortnight 
after the reception of the injury. 

The following table exhibits the results of the operations for 
amputation of limbs at the Massachusetts General Hospital, 
from January, 1822, to January, 1866, — a period of forty- 
four years : — 





TOTAL. RECOVERED. 

i 


DIED. 


PER CESTT 
OF DEATHS. 


Thigh 

Leg 

Arm 

Fore-arm 

Hip-joint 

Shoulder-joint 


204 
196 

65 
53 

2 

19 


149 
139 

55 
45 

1 

12 


55 
57 

10 
8 

1 

7 


26.96 

29.08 

15.3 
15.09 

50. 
36.8 


Total 


539 


401 


i 
138 1 25.6 

1 



EXCISION OF JOINTS. 

The excision of diseased joints, as a substitute for amputa- 
tion, which was revived some years ago by Mr. Syme, — more 
particularly for the elbow and shoulder, — has since been prac- 
tised on most of the larger joints of the body, and has passed 
into surgery as one of the established operations. The excision 
of the knee, in particular, has been much more frequently per- 
formed than that of any other large joint ; the diseases which, in 
civil practice, require surgical interference, being more frequent 
in the case of the knee than of the elbow. By this operation, 
many limbs, which would otherwise be condemned to amputation, 
are saved, and made useful. Excision of the knee is, of 
course, applicable only to cases in which the limb is otherwise 
sound, and the movements of the hip and ankle unimpaired. 
Performed upon adults, it already counts a great number of 

62 



410 EXTREMITIES. 

most admirable results : but, in the case of young children, a 
very grave objection has arisen from the fact, that, in several 
instances, at first reported as successful, the growth of the 
limb has been arrested ; leaving it, at last, many inches shorter 
than its fellow. There is no doubt, that, if the epiphyses of 
the bones are wdiolly removed, the subsequent growth of the 
limb is impaired. It is therefore proper, in children, to pare 
off from the articular surfaces as thin a slice as is consistent 
with the removal of the diseased bone and the whole articular 
cartilage. One case in my own practice, given below, in a 
little girl of about elglit years of age, an entirely useless and 
bent-up limb, the result of scrofulous white swelling, was made 
serviceable by removing the ends of the bones, and straightening 
the joint. I saw this patient, at the end of three years, perfectly 
well, and walking wdth a sliglit limp. The limb was shorter 
than the other ; but the pelvis had so adapted itself as to make 
the loss of length less evident than might have been expected. 

I have performed excision of the knee-joint three times, for 
caries, with most gratifying success. In a fourth case, — that 
of an adult female, — which, from the first, seemed a less prom- 
ising one for the operation than the others, amputation was 
afterwards necessary. 

In two or three excisions of the shoulder-joint for caries, the 
results have all been successful. 

The advantao'es of excisino; the head of the humerus and the 
articular surfaces entering the elbow-joint are undoubted. 

Barton's operation, removing a wedge-shaped piece of bone 
for a contracted and distorted limb, is one well worthy of imita- 
tion. I have introduced below two cases in illustration of it. 

Case CCXLY. — Excision of External Condyle of Right 
Humerus, — Nov. 27, 1854. A man, 24 years of age, being 
on the cars while they were in motion, stepped ofiP, and was 
thrown against a rail, which penetrated his arm above the elbow, 
tore open the integuments, and broke the external condyle into 
the joint. He entered the Hospital the same day. I saw him 
first on the 29th. The arm was then swollen, and there was a 
moderate discharge from the wound. The condyle was com- 



EXCISIOX OF JOINTS. 411 

pletelv loose and denuded, so that it was dissected out and 
removed without any great difficulty, and the wound left open. 
On the following day, a yeast poultice was applied to the el- 
bow. On tlie 13th of December, a small abscess formed on 
the elbow, which Avas opened, and discharged freely. In order 
to support it with as little pressure as possible, the arm was laid 
on a bladder partly filled with water. Jan. 10th, another ab- 
scess formed on the outside of the wound, which had then nearly 
healed up. On the 20th of January, he left the Hospital, the 
wound entirely healed, the joint possessing but little motion. 

About six months afterwards, he presented himself, having 
recovered a good motion of the joint. 

Case CCXLYI. — Excision of the Shoulder- joint for 
Caries. Recovery. — 1853. The patient was a man, 60 
years of age. Three years before, the disease first manifested 
itself by a pain in the shoulder. In 1852, swellings appeared 
about the middle and outer part of the arm, which were opened, 
and gave issue to a large quantity of pus. The inner part of 
the arm was soon after affected in the same manner; also, over 
the pectoral muscle on the thorax. The openings left by these 
abscesses were probed, but no dead bone could be discovered. 

The motions of the shoulder-joint became almost abolished ; 
and the discharge of pus was so large, from the fistulous openings 
in the arm, as to greatly weaken the patient. An incision was 
therefore made from the oj)ening nearest the shoulder -joint 
towards the head of the bone, which was found to be carious, 
though not extensively so. The wound was kept open in the 
hope that anchylosis would take place, and thus avoid the neces- 
sity of an operation. 

A month later, no improvement having taken place, the 
patient Avas etherized, and the old incision enlarged. The os 
humeri and glenoid cavity were found to be carious to such a 
degree that an operation was absolutely necessary ; and it was 
performed as follows : — 

A triangular flap was raised from the shoulder, so as to ex- 
pose the head of the bone. The strong adhesions between it 
and the socket were then cut through, which, with a little dis- 



412 ' EXTREMITIES. 

section, allowed the head of the bone to be turned out and 
sawed off. The socket, being carious, was next removed by the 
cutting forceps. The wound was closed by a few sutures, and 
some strips of adhesive plaster applied. 

At the time when he left the Hospital, the discharge from the 
various sinuses was decreasing rapidly ; and the large cavity 
left by the operation had been quite filled up. His health was 
excellent. 

I saw this patient again in 1855. His condition was as fol- 
lows : The left shoulder, front part of the chest, and integu- 
ments over the scapula, were covered with puckered cicatrices, 
the result of the numerous abscesses caused by the original dis- 
ease. The upper part of the shaft of the humerus was a little 
in front of the old glenoid cavity. The motions of the fore-arm 
and hand were perfect, so that he was able to work at his em- 
ployment — stocking- weaving — for ten hours a day, which re- 
quires the constant motion of these parts. To facilitate the use 
of them, and to relieve the shoulder, a sling was suspended from 
the ceiling, in which the arm was placed ; and, by this means, 
he suffered no inconvenience from the constant strain which 
otherwise would have fallen upon it. He had the full command 
of his hand and fingers, and could grasp things with nearly as 
much strength as with the other hand. He could not raise the 
hand to the mouth without inclining the head a little forwards ; 
nor could he extend the arm to its full length, directly before 
him. With these exceptions, he could move the limb in all 
directions. 

Case CCXLYH. — Excision of the Knee-joint. — D. L., 
32 years old, a handsome, fresh-looking man, five feet eight 
inches in height, entered the Massachusetts General Hospital, 
March 23, 1857, for an aiFection of his right knee. Three 
years before, he had what was supposed to be a rheumatic attack 
in this joint, which lasted three weeks. Five months previously, 
the knee became painful and swelled, and he was confined to his 
bed for three weeks with it, but afterwards was able to walk 
without crutches. When he entered the Hospital, the joint 
measured three inches more in circumference than the sound 



EXCISION OF JOINTS. 413 

or left knee. There was great thickening of the capsule, which 
gave the impression of its having undergone a long inflam- 
matory process; there was also fluctuation, but no pain except 
on free motion. 

A gutta-percha splint, extending from the hip to the toes, 
was moulded to the back of the limb, so as completely to pre- 
vent the motions of the knee and ankle joints. Counter-irri- 
tation was made by the free use of the tincture of iodine. Under 
this treatment, the knee-joint, in four weeks, had diminished an 
inch in circumference. As the absorption, although gradually 
progressive, did not seem to be going on with sufficient activity, 
two deep issues were made, on May 7th, above the joint; and, 
on the 20th, two more below. The improvement from these 
applications was very great, so that on June 16th, at his own 
request, he was discharged from the Hospital, much relieved. 

This patient kept about until June 2, 1858, when he again 
entered the Hospital, by my advice ; the disease having as- 
sumed a more troublesome form. The knee was quite painful, 
at times swollen, and almost useless. He was unable to bend 
it, and was obliged, in walkings to swing the limb forward 
between his crutches. It was his wish to have amputation per- 
formed ; but, on consultation, it was decided to give him the 
chance afforded by excision of the joint, and he readily con- 
sented to follow my advice. The operation was performed on 
June 5th, in the following manner : A semilunar incision was 
made, commencing over the inner condyle of the femur, ex- 
tending down to the tubercle of the tibia, and terminated over 
the outer condyle. The whole flap was dissected up, and the 
joint exposed. Some adhesions existed, and an attempt at an- 
chylosis had been made ; but the cartilages were in a great 
measure destroyed, and the bones eroded. The patella was 
firmly fixed to the femur, and did not participate in the disease, 
so that it was determined not to interfere with it. The condyles 
of the femur were sawn oflP, as also was the head of the tibia, by 
a narrow saw, like Butcher's, which was arranged to cut on the 
inner instead of the outer edc^e, the saw beins" reversed in 
the handle. This was engaged under the condyles of the femur, 
and divided the bones with the accuracy of a knife. A common 



414 EXTREMITIES. 

saw would not have been available, in consequence of the pro- 
tection of the patella ; and, but for this arrangement, a chain- 
saw would have been required. On the top of the tibia, a 
tubercular deposit still remained, which was completely removed 
by a gouge, leaving a cavity about a quarter of an inch deep. 
The head of the tibia was so cut as to leave its edges a little 
more dependent than the centre, in order to favor the escape of 
fluids. The bony surfaces being carefully placed in apposition, 
the flap was secured in its situation by numerous sutures, and 
the wound covered with a little scraped lint soaked in blood. 
There was very little hemorrhage, and only two small arteries 
were secured. The limb was then placed in a gutta-percha 
splint, nicely padded, which had been carefully prepared before 
the operation, and moulded exactly to its shape. The splint 
reached from the nates to the foot, so that the whole of the lower 
extremity was perfectly confined. 

For the three days subsequent to the operation, the patient 
slept well, without pain in the knee or fever. On June 8th, 
when the leg was raised from the splint and dressed, the wound 
was found to have united, except at the outer edge, where there 
was a discharge of pus. He was remarkably comfortable, and 
experienced but little pain from the dressing. He was allowed 
house diet. 

On the 11th, the limb was again taken out of the splint, and a 
collection of pus was found on the outer, but none on the inner 
side. The appetite was not very good, and he was therefore 
ordered the compound tincture of gentian. On the 14th, the 
limb was again dressed, and the wound was found to have dis- 
charged somewhat more than at the last dressing. The incision 
below the patella had apparently united by the first intention, 
and only the ends were open to allow the escape of the pus. 
His appetite was much better. 

This patient continued to improve, and left the Hospital in 
about two months, not having had a bad symptom from the date 
of the operation. In November, he was present at a meeting of 
the Boston Society for Medical Improvement, having walked 
nearly a mile from his residence. At this time, he was partially 
disabled by a nail growing into the flesh of one of the toes on 



EXCISION OF JOINTS. 415 

the side operated upon, so as to require the use of two canes in 
walking. Bony union seemed to have taken place between the 
femur and tibia. The wound had apparently healed ; though, at 
a small spot, it occasionally opened, and discharged slightly. 

The recovery of the use of the limb in this case was quite 
rapid, and he was out as soon as a patient after an ordinary 
amputation. The superiority of the single over the double flap, 
when it can be made, both as regards appearance and position 
of the wound, need hardly be insisted on. 

Case CCXLYIII. — Excision of the Knee-joint for Caries. 
Hecovery. — A girl, 14 years of age, of light complexion and 
red hair, entered the Hospital on April 28, 1859, during my 
service. About six years before, she had an affection of the 
right knee-joint, the origin and course of which she was utterly 
unable to describe, which left her lame, and the limb slightly 
contracted. Nine months before coming to the Hospital, she 
entered a factory in Lowell, where, for a good part of the day, 
she was obliged to keep her knee in a bent position against the 
machine at wliich she worked. This brought on a recurrence 
of pain in the joint, some swelling, and further contraction of 
the limb, so as to disable her from walking, and require local 
applications to relieve the tenderness of the joint. She came to 
the Hospital with the idea of having the limb removed, if it were 
thought advisable by the surgeons. 

The right knee-joint was about one-third larger in circumfer- 
ence than the other, and the natural depressions about it were 
obliterated. The leg was bent on the thigh, so that, on standing 
up, the toes did not reach the floor by nearly two inches ; the 
diseased knee being pressed against its fellow, and the inner 
edge of the foot coming to the ground. The surgeons of the 
Hospital agreed with me, that the case was a very favorable 
one for excision of the joint, and that this operation was to be 
preferred to removal of the limb. 

On the 30th of April, she was etherized ; and I made a horse- 
shoe incision over the knee-joint, whicli was found to be closely 
invested by a dense covering, consisting of the disorganized 
synovial membrane and cellular tissue : the cartilages were 



416 EXTREMITIES. 

eroded at many points, and the condyles of the femur and head 
of the tibia were necrosed. About half an inch was sawed from 
the femur, and a quarter of an inch from the head of the tibia ; 
all the diseased bone was removed, and the patella dissected out. 
There was very little hemorrhage. The femur and tibia were 
brought into proper apposition, care being taken that the excised 
ends should not be too tightly brought together ; the flap was 
confined by sutures ; and the limb placed in a gutta-percha splint, 
and bandaged. 

She passed a comfortable night, and did well, except that 
twice the action of the femoral muscles drew the tibia out of 
position, backwards and upwards. The patient, being of a 
scrofulous habit, emaciated, and of poor vitality, her convales- 
cence was slow ; and the limb required a good deal of manage- 
ment, by splints and dressings, to keep it in a good position, and 
promote the healing of the wound. She was taken out of doors 
early, and every means used, by food and tonics, to invigorate 
the system. It was not, however, until September, that she 
was sufficiently well to leave the Hospital, when the joint was 
firm. A slight superficial wound still remained. She was 
taken to her relations in California, and her future history is 
unknown. The case promised to be of successful issue. 

Case CCXLIX. — Excision of the Knee-joint for De- 
formed and almost Useless Limh. Cure, — A girl, 7 years 
old, born in China, was brought to the Hospital in April, 1861, 
for the purpose of having either the knee-joint excised or the 
limb amputated. Her parents were still abroad, and no satis- 
factory account of the case could be obtained. The knee was 
bent at nearly a right angle, and the patella was fixed. On 
attempting to walk, she came down upon the toes with a most 
awkward and hobbling^ o^ait. Her health was otherwise o-ood. 
Excision was performed on the 24th of April. A semicircular 
flap was made in front of the joint, exposing the articulation. 
As delicate a slice as possible was then excised from the ends 
of each of the bones, by means of Butcher's saw. The patella, 
becoming detached, was removed. The bones were then ap- 
proximated, the limb being straightened, and the flaps nicely 



EXCISIOX OF JOINTS. 417 

adjusted by sutures. The limb was then placed in a gutta- 
percha splint, which had been previously moulded to the proper 
shape, and secured by a bandage extending from the toes to the 
pelvis. She was not much depressed by the operation, but 
passed a restless night, and for two or three days was in an un- 
comfortable state. On the 27th, the wound had the appearance 
of having united by first intention ; but, on the 30th, there was 
a slight discharge of pus. May 24th, nearly all the discharge 
had ceased ; and, on the 28th, it was found that the bones had 
united. June 24th, a starched bandage was applied, instead of 
the gutta-percha splint ; and she was taken out daily into the 
yard, and exposed to the sun. By the middle of July, she was 
able to walk, and, at the end of August, was discharged well. 

I saw this patient about a year after the operation, and exam- 
ined her carefully. The knee-joint was slightly flexed, from the 
weight of the body ; and the limb appeared to be about two 
inches shorter than its fellow. The pelvis, however, had yielded 
so as to compensate for the loss in length in the limb, which 
appeared to be due in part to the want of nutrition, the limb 
having grown less than the other. She walked with a very 
slight limp ; and the change produced by the operation was very 
striking, a serviceable limb being substituted for a deformed 
and useless one. 

Case CCL. — Excision of Wedge-shcqoed Piece of Boyie 
from Knee-joint for Anchylosis. Death from Pyo^mia. — 
A boy, aged 14 years, of large size, and good muscular devel- 
opment, in 1855 received a wound from an axe, on the right 
knee, which penetrated the joint. The injury was followed by 
severe and long - continued inflammation of the joint, finally 
resulting in an anchylosis, with the leg bent at a right angle 
with the femur. When I first saw him, he walked on the tip 
of the toes of the rio^ht foot, the left limb beino^ thrown, in a 
bent position, forwards ; so that a person seeing him in motion 
would suppose the whole osseous system more or less distorted. 
Being consulted in November, 1859, as to the possibility of 
straightening the limb by any mechanical force applied to it, I 
at once decided in the negative ; the patella being firmly fixed 

63 



418 EXTEEMITIES. 

in its situation, and all motion of the joint, so far as could be 
perceived, destroyed. The only method of relief I could pro- 
pose to him was an operation like that first suggested by Dr. 
Barton, of removing a wedge-shaped piece of bone from the 
joint, or its vicinity, which I had once before practised with 
success ; that removal of the limb , even , was more desirable 
than allowing him to continue in his deformed and painful con- 
dition. His friends and physician, having taken the subject into 
full and deliberate consideration, decided to have the operation, 
which I proposed, performed ; and the patient was brought 
down from the country, and placed under my charge at the 
Hospital. 

The operation was done on Oct. 29, 1859. Previous to its 
performance, it Avas observed that the hamstring tendons in 
the different motions of the limb were powerfully contracted ; 
and, in four or five cases of excision of the knee-joint which I 
have performed or witnessed, I have observed that these tendons 
formed an obstacle, at the time, to the straightening of the limb, 
and were very troublesome afterwards, during the treatment, 
dragging the leg backwards out of apposition with the femur. 
The operation was commenced, therefore, by the subcutaneous 
division of these tendons. The patient then being placed upon 
his back, a semicircular incision was made just over the knee- 
joint, commencing at the lower part of the inner condyle of the 
femur, extending around across the spine of the tibia, and ter- 
minating at the outer condyle. The flap of skin was then dis- 
sected up, and the remaining soft parts divided to the bone. 
The saw was next placed on the femur, just above the anchy- 
losed patella, and the bone sawn a little obliquely downwards, 
so as nearly to traverse its thickness. The saw was then placed 
on the upper part of the tibia, just below the point where the 
old articulation was supposed to have been, and an incision 
made nearly at a right angle with the former, so as to remove 
a solid bit of bone, with the patella attached to the top of it. 
With a very little motion backwards, the remaining shell of 
bone was now fractured ; and the size and shape of the piece 
removed were so exactly what had been intended, that it seemed 
as if there could be no difficulty in placing the limb at once in a 



EXCISION OF JOINTS. 419 

straight position : but, for some reason which could not be ex- 
plained, and which was unconnected with muscular action, it 
was found impossible to do this, — a result I attributed to the 
head of the tibia having been partially displaced behind the 
femur ; and thus, while the whole circumference of the femur 
had been removed, only a part of the head of the tibia had been 
included in the incisions. The le<x beino' bent forcibly back- 
w^ards, so as to protrude as much as possible the ends of the 
bone, and the intervenino' bit of bone beini>' cut awav, the ends 
of both bones were fairly exposed, and a slice removed from 
each of them. The limb could now be brought out straight, 
and the eversion of the foot corrected. Liston's splint was 
applied, and the edges of the wound nicely adjusted by sutures. 
The hemorrhage, during the first incisions, was much more free 
than in any excision of the knee-joint I have practised. It was 
partly owing to the age and muscular development of the pa- 
tient. The bony structure itself was also excessively vascular. 

In the afternoon, the patient, having recovered from the 
effect of the ether, and having taken twenty drops of laudanum, 
was quite free from pain. There had been an oozing of blood, 
wdiich wet the bandages in the vicinity of the joint. He passed 
a moderately quiet night, and on the following day made no 
complaint of pain, his pulse being between seventy and eighty 
in the morning. Towards evening, considerable re-action took 
place, attended with some heat of the limb, and fever. 

On the next day, he was quite comfortable, complained of no 
pain, and began to take nourishment. The bandages, being 
foul, Avere removed as fiir as possible without disturbing the 
limb. 

On the fourth day, the limb was taken completely out of the 
splint, entirely cleansed, and fresh dressings applied. The pa- 
tient took cider, broth, and coffee, and expressed himself as 
getting along well. AVith the exception of an aperture on the 
inner side, at which the blood had escaped, the wound had 
united througliout by the first intention. A little redness 
existed over the outer side of the condyle of the femur ; and the 
patient having rolled over, on the first night after the operation, 
partly displaced the bone, and kept up undue pressure on it 



420 EXTKEMITIES. 

through the night : the displacement was discovered, and ad- 
justed on the ensuing day. 

Every thing appeared very favorable until the seventh day 
after the operation, when he began to show some unfavora- 
ble symptoms : the pulse became more rapid, a languor and 
heaviness appeared, a disposition to sleep, and more or less loss 
of appetite. At the same time, the discharge from the wound 
became offensive. He was immediately put upon full doses of 
brandy and quinine, and great attention given to the wound, by 
frequent dressings and ablutions, to free it from the foul secre- 
tions as much as practicable. During this time, the limb above 
and below the wound looked well, and the circulation seemed 
to be perfectly normal. On the following day, an injection was 
made into the wound, three times, of the tincture of iodine. 
The symptoms of purulent absorption rapidly became more de- 
cided. The patient was very listless ; the pulse 120 : he made 
no complaint of any kind. By the next day, the skin over a 
portion of the flap covering the former joint had a sloughy look ; 
and towards evening, in addition to former symptoms, he had 
difficulty in opening his jaws. He sank, and died on the fol- 
lowing day, being the twelfth from the operation. 

The body being immediately removed, no opportunity was 
afforded of making an examination. The symptoms were all 
those which would be caused by absorption of a poisonous 
material into the circulation, and were met, as far as could be, 
at once, when perceived. The part at which the operation was 
done was inspected, and the bones had all the appearances of 
having been bathed for a number of days in fetid secretions. 
There were no abscesses or collections in the vicinity. 

Case CCLI. — BartorCs Operation for Straightening 
the Knee-joint hy Excision of a Wedge-shaped Bit of Bone, 
— A man, 25 years old, from Nova Scotia, presented himself 
to me in September, 1850, on account of a great deformity of 
his limb, owing to an anchylosis of the knee-joint ; the leg being 
bent at nearly a right angle with the thigh. He stated that his 
prospects had been destroyed and his life rendered wretched by 
his infirmity ; and wished, if any thing could be done for him, 



EXCISION OF JOINTS. 421 

short of extreme danger to his life, that it should be attempted. 
The history of the case, as given by him, was this : In Novem- 
ber, 1841, he fell a distance of three feet, striking the knee. 
Three days after the fall, the knee began to swell, and become 
painful. This went on for four weeks, when it was punctured, 
and a pint of watery fluid escaped. It continued to discharge 
for fifteen months, during which time many small pieces of bone 
came away. The opening finally healed, leaving the joint and 
limb in a distorted position. His hereditary tendencies were 
scrofulous. In the erect position, resting upon the sound limb, 
the lame foot was seven and a half inches from the ground ; but 
he could limp about with a high-heeled boot. 

I informed the patient, that the only operation which sug- 
gested itself to me was Barton's operation, which had apparently 
been already described to him ; and at once he requested to have 
it performed. I advised him to enter the Hospital for the con- 
venience of apparatus, which he did. Some of his friends 
attempted to deter him from running any risk ; but he said he 
was determined either to undergo the operation suggested by me 
or to have the limb removed, as he could no longer bear the 
pain and mortification of his condition. 

On the 2d of October, the operation agreed upon was per- 
formed as follows : A Y-shaped incision was made through 
the skin just above the knee-joint; the base of tlie triangle, two 
inches wide, presenting outward, with the apex at the inner side 
of the limb. The flap was dissected up, and the bone ex- 
posed ; the other textures having become atrophied from disease. 
A wedge-shaped piece was sawn out of the femur ; the saw 
not being carried quite through, so as to avoid the artery. The 
remaining portion of bone was then broken ; the flap was se- 
cured in its place, and the knee placed on a double inclined 
plane, and firmly fixed to it. There was no hemorrhage. 

On the following day, the patient said he had passed a rest- 
less night, but was free from pain. The limb was dressed on 
Oct. 7th, and placed on a splint with a hinge and screw, so 
that it could be extended without any shock to the joint. By 
the 20th, the limb had been gradually brought to a straight 
position; and, on the 29th, the bones had united, and the 



422 EXTEEMITIES. 

wound was healed. Some time after this, he had a febrile at- 
tack, in the course of which the union became somewhat less 
firm, and threatened to dissolve ; the system showing its scrofu- 
lous tendency. He gradually recovered, however, and left the 
Hospital. 

About a year after his discharge, this gentleman presented 
himself to me, well. The limb was very little shorter than the 
other ; and, with a pair of large trousers, the difference in 
the shape of the two limbs could scarcely be distinguished. He 
walked well with a cane ; and the improvement between his 
upright appearance in walking and his former method of loco- 
motion would have almost prevented him from being recog- 
nized as the same individual. 

In some cases, greater symmetry may be gained by making 
the excision directly from the joint, rather than above it, as 
there is then presented a much larger surface of bone. 

The followino^ table ogives a brief resume of the cases of ex- 
es o 

cision of the joint before described, not including the two cases 
of Barton's operation : — 



EXCISIOX OF JOINTS. 



423 



1 

i" 

"5 
2 
e 
1 
1 
i 
1 


Treated with straight splint; 
slight suppuration ; union 
almost wholly by first inten- 
tion ; perfectly well in 2 mos , 
and remains so now, G years 
after. 

Straight splint; healed with 
some suppuration ; could 
walk in 4 mos. ; end of 5 mos , 
well. Seen 1 yr after opera- 
tion. Slight flexion, iind limb 
tipparently 2 in. shorter than 
other, but compensated by a 
deviation of pelvis; walked 
with very slight limp. Is still 
well, 4 yrs. after. 

Walked sifter 3 mos. ; straight 
splint; a small fistulous open- 
ing left when discharged. 
Went to California, and not 
since hetird from. 

Straight splint; great suppu- 
ration; wiint of union ; final 
amputation, and recovery. 

Recovery with almost com- 
plete use of arm. Seen 2 yrs. 
later, with bone a little in 
front of noruiiil position ; mo- 
tions of fore-arm perfect. Is 
employed 10 hours a day in 
stocking-weaving, an occupa- 
tion which retiuires the very 
free use of tlie limb; very 
free motion at shoulder. 

Great hemorrhage at time; 
healed by granulation ; 3 nis. 
after, still fistulous opening 
on top of sliould(!r; 10 mos. 
after, two openings; but no 
bone to be felt in either. 
Cure but partially successful. 


i 
1 


Semilunar inci.sion ; condyles of 
femur and head of Tibia 
sawed olT; ptitella left, adher- 
ent to femur. 

Semilunar flap, patella remov- 
ed; also, both articular sur- 
faces, thin slice of each. 

Whole joint excised, patellti 
removed; thin slice from 
femur and tibia. 

Semilunar flap; whole joint and 
large mass of disetised tissue 
removed ; patella healthy, not 
removed; much bleeding. 

Triaiiguliir flap, head of bone 
and socket removed. 

Head of bone sawed off; socket, 
which was loose, removed 
with forceps. 


CoiuUtion nt timo of Oper- 
ation. 

General condition good; 
knee swollen, stitt', and 
painful. 

General condition good; 
knee bent at right angle, 
fixed. 

Much swollen, bent, and 
also abducted ; limb use- 
less. General condition 
feeble. 

Very severe pain in joint; 

swollen; straight, and 

very tender. Health 

failing. 
No motion of joint; great 

purulent discharge. 

Whole joint diseased. 


o 


3 years. 
Several years. 

9 mos. ; knee had 
not been well for 
G years before ; 
slightly contract- 
ed and lame. 

2 years. 

3 years. 
6 years. 


1 

5 

o 

1 
5 


Rheumatism. 
Strumous disease. 

Scrofula. 

No local cause. 
Caries. 

Caries. 


s 


Knee. 
Knee. 

Knee. 

Knee. 

Shoulder. 

Shoulder. 


?! 

I 


Healthy. 
Strumous. 

Very scrofulous. 

Scrofulous. 
Healthy. 

Healthy. 


1 ig fe" =: '^ ^. s 


32 years. 

7 yrs., 9 mos. 

14 years. 

19 years. 
GO years. 

41 years. 



CHAPTEE IX. 

ARTERIES AND VEINS. 

ANEURISMAL TUMORS AND LIGATURE OF ARTERIES. 

The introduction of the method of treating aneurismal tumors, 
either by compression on the vessel above the tumor, or com- 
pression on the tumor itself, in the place of the severe and 
dangerous operation of tying the artery, gave an additional 
impulse to the treatment of these diseases. The distinguished 
surgeon, Mr. Syme, has advocated a revival of the old opera- 
tion of opening the sac itself, and tying the vessel above and 
below, in appropriate cases. 

The following cases illustrate, by one or two examples, the 
treatment of compression of the tumor directly. An interest- 
ing case of femoral aneurism treated by immediate compression, 
under the care of Dr. B. Brown, which I saw in consultation, 
is published in the " Boston Medical and Surgical Journal " of 
March 15, 1866. The tumor in this case was in the femoral 
artery, just at its exit from the pelvis. The compression was 
made by means of ingenious apparatus, continuing through a 
period of about eight months, and with full success ; substitut- 
ing a treatment without danger for the very serious operation of 
the ligature of the external iliac artery. One or two cases are 
given of the old Hunterian operation, and one where death oc- 
curred after ligature of the jpjarotid artery from the recurrent 
circulation. The compression may be made either with the fin- 
gers, — in which case it is kept up for several hours by relays of 
assistants, — by long-continued and extreme flexion of the limb, 
or by special instruments contrived for the purpose. In two 
cases of very large subclavian aneurism, which I have treated 
by the direct pressure upon the tumor of a heavy weight, in the 



II. 




ANEURISMAL TUMORS. 425 

shape of a cannon-ball, and where the Hunterian operation was 
impossible, I have been so fortunate as, in one instance, to effect 
the complete obliteration of the artery ; and, in the other, to 
produce coagulation of the contents of the sac, followed by sup- 
puration and sloughing, resulting in the perfect cure of the 
disease. 

Case CCLII. — Subclavian Aneurism treated hy Com- 
pression and other Means. Recovery. — (Plate II.) A col- 
ored man, 39 years of age, from Machias, Me., was sent to 
me, March 2, 1854, having a large aneurism of the left subcla- 
vian artery. I was called down stairs early in tlie morning 
by the statement that a black man in a dying state was lying 
under the staircase. The patient stated that he left Gloucester 
in a vessel about a week before, and had been kept out by stress 
of weather, and finally had been landed at a distant point, from 
which he had Avalked to Boston. He was suffering much from 
excessive pain in his arm, which was enormously swollen, had 
an asthmatic cough, and great dyspnoea. He was immediately 
transported to the Hospital, where, being placed in a warm bath 
and thence into bed, the circulation became more free ; and he 
gradually got into a more comfortable condition. The following 
account is taken from the Hospital records : — 

"Hard-working man ; strained himself fourteen months ago. 
Has had uneasy sensations about shoulder since that time. First 
noticed tumor above clavicle in July, 1853 ; worked until Feb. 
22, 1854, when pain in tumor and arm obliged him to quit. 
Now, pulsating tumor over clavicle, its anterior inferior portion 
one inch from sternal end of clavicle. Circumference of tumor, 
7i inches. Hand and arm have been swollen all winter." 

After his admission to the Hospital, a consultation of all the 
surgeons was called, and the question proposed as to the pro- 
priety of any operation being attempted for his relief. The 
whole triangle of the neck above the clavicle was filled with the 
tumor, which extended nearly to the sternum, so that any pros- 
pect of tying the vessel on the cardiac side seemed to be imprac- 
ticable : and the only operation which was at all feasible was to 
apply a ligature to the artery, as it issued from the tumor, be- 

54 



426 ARTERIES AND VEINS. 

low the clavicle ; a project hardly worth attempting. The 
following treatment was therefore resorted to : — 

From the 12th of March to the 30th of April, cold applica- 
tions were made to the aneurism, varied with compression by 
weights. There was no diminution in its size, indeed it rather 
increased during his stay in the Hospital ; nor much ameliora- 
tion in the symptoms, except that of pain, which was entirely 
assuaged by means of compression. The patient's general 
health was considerably improved. 

May 4th. Discharged much relieved. 

On May 1st, being obliged to leave Boston for Europe, I lost 
sight of this patient. Some months after leaving the Hospital, 
he was admitted to the State Hospital at Rainsford Island, where 
he came under the care of Dr. J. R. Lothrop, physician and 
surgeon of the place, and now of Chicago, who has been kind 
enough to give me the sequel of this remarkable case. 

" As nearly as I can remember, Williams was admitted to the 
Hospital at Rainsford Island in October of 1854. He stated 
that he had fallen upon the shoulder of the affected side a few 
days before, and suffered much pain in consequence. The 
tumor was tender to the touch ; motion gave great pain ; and 
the only position which he could bear, was to lie on the sound 
side. The skin over the tumor was tense and shining ; there 
was no pulse at the wrist ; his arm was powerless and oederaa- 
tous, and dropped, as can be seen by the picture. The tumor 
had more the appearance of a large abscess than of an aneurism. 
There was no tremor or pulsation in it, or communicated to the 
hand ; no sound or aneurismal murmur. 

"In about three weeks the pain ceased, and the patient was 
able to get up and put on a shirt for the first time ; rallying 
quickly from the effects of the general constitutional disturbance, 
which had been quite severe. 

" In time, the tumor began to point perceptibly nearly over the 
middle of the clavicle ; the skin gradually becoming thinner. I 
do not recollect the time when spontaneous rupture took place ; 
but I think it was during March, 1855. 

"When the opening took place, there was a profuse discharge 
of mixed blood and pus, dark and rather thick; in quantity 



ANEURISMAL TUMORS. 427 

about two quarts. It continued to flow two or three days, 
gradually decreasing. A purely purulent discharge continued 
for several months : in fact, when the patient was discharged in 
June, there was even then a slight flow of pus from the open- 
ing. No bad symptoms accompanied or followed the spontane- 
ous opening of the tumor : on the contrary, Jack was in high 
spirits at an event which he had all along been wishing for, the 
getting out of the ^corruption.' He had predicted, that, when 
the ^ corruption ' was all out of it, he should be all right ; and 
he often be^'oed me to ' launch ' it. In a short time after the 
rupture, he was up and about. 

" The tumor rapidly subsided, and w^as followed by a depres- 
sion. The shoulder fell forward. An opening remained one- 
half or three-fourths of an inch in diameter, into which opening 
projected a pointed and carious end of the humeral portion of 
the clavicle. The sternal portion was not visible. The middle 
portion was wanting. When he left the hospital, he had no 
distinct pulse at the wrist, and the arm was still powerless ; but 
his general health had greatly improved, and he felt himself able 
to resume his old employment of ship's cook, which he actually 
did soon after. 

" About a year after Williams left the hospital at Eainsford 
Island, he presented himself at the boat-house in Boston, with 
his arm in a sling, but otherwise in good health ; and I under- 
stand that a letter has since been received from him, in which he 
stated that his health continued good." 

Case CCLIII. — Aneurism of the Right Subclavian, 
Treatment by Compression. Cure. — May 14, 1857, a me- 
chanic, from Scotland, 41 years of age, came under my care, 
having an aneurism of the subclavian artery, occupying the 
whole triangle of the neck above the clavicle. The tumor, 
when first noticed, thirteen months previously, was situated 
about the middle of the clavicle. Being a strong, active man, 
in the enjoyment of good health, he gave very little attention to 
it at first. He had been employed twenty-seven years in the 
manufacture of steam-engines, and much exposed to changes of 
temperature. 



428 ARTERIES AND YEINS. 

The tumor presented three projections ; and, from its original 
size of a pigeon's egg, had extended the whole length of the 
clavicle. As it increased, he began to suffer from pain in it, 
attended with shortness of breath. On stooping, a sensation 
of weight, accompanied with throbbing, was produced in it. 

'No operation seemed feasible in this case, and it was there- 
fore submitted to the following treatment : He was placed on 
his back, in bed, and kept on a limited diet of a pound of solid 
and a pint of liquid food every twenty-four hours, without meat. 
Bags of ice were applied to the aneurism on the 17th, and, in 
less than two hours, produced a very sensible effect in reducing 
the pulse. On the 19th, compression was tried with Dr. Ar- 
nott's air-cushion, "\thich was applied through the day, with the 
exception of three intervals of half an hour each, when bags 
of ice were substituted. On the 21st, he complained of more 
pain in the lower lobe of the tumor ; also some in the two 
upper lobes, and a feeling of numbness in the arm of that side. 
Ice was used for fifteen minutes, instead of half an hour. Com- 
pression was discontinued, from the impracticability of making 
it equally over the whole tumor, on account of its irregular 
surface and large size. On the 27th, having complained of 
more pain in the smallest projection, the ice was discontinued. 
On Aug. 12th, he left the Hospital, apparently not much re- 
lieved : but, in fact, from this time the tumor gradually sub- 
sided ; and, about a year afterwards, he came to the Hospital, 
and said that the tumor had entirely disappeared, and he was 
quite well. Unfortunately, I did not see him at the time, and 
was unable to verify the exact condition of the subclavian artery 
and pulse of that side. 

Hemarks. — The ice and compression, together with rest, 
seem to have given an impetus to the tumor in both cases ; in 
the one leadinsf to an obliteration of the sac, and in the other to 
suppuration and a destructive inflammation. The appearance 
of the tumor in the former case, when first seen by Dr. Lothrop, 
some months after leaving the Plospital, being such as to lead 
him to suppose it a large abscess, and that some error must 
have been made in the diagnosis at the Hospital as to its aneu- 
rismal character ; so entirely unlike such an affection did it appear 



AXEUEISMAL TUMORS. 429 

to him at that time. Whether owinof to treatment or to natu- 
ral causes, the ultimate recovery of two such apparently formid- 
able and desperate cases is worthy of record. 

Case CCLIV. — Ligature of the Left Subclavian Artery 
for Subclavian Aneurism, with a Remarlcable Deviation of 
the Vessel, and Consequent Change of its Relations. — The 
great mortality attending the ligature of the larger arterial 
trunks, and of the subclavian in particular, gives importance to 
any operation on those vessels. In the latter the danger is in- 
creased by its deep situation, — causing, in many cases, a great 
difficulty of reaching it, — and by the importance of the organs in 
its immediate neio^hborhood. Accordino- to the valuable tables 
furnished by Dr. Xorris, out of 69 cases of ligature of the sub- 
clavian artery, 36 recovered, and 33 died, or nearly one-half. 
In operations on the iliac arteries, out of 118 cases, 85 recov- 
ered, and 33 died. From 38 cases of operation on the carotid 
artery for aneurism, 22 recovered, and 16 died. In every in- 
stance where it has been necessary to place a ligature on the 
subclavian artery, on the tracheal side of the scaleni muscles, 
the result has been fatal. 

The case which I propose to relate offers some peculiar points 
of interest, apart from the general one of the ligature of the 
vessel. Among the principal of these may be mentioned the 
fact of a ligature having been applied to the artery for an aneu- 
rismal tumor situated above the clavicle ; being, so far as I am 
aware, the first case of this kind that has had a successful result, 
because the recorded aneurismal tumors in that situation have 
required the application of a ligature within the scaleni, and the 
termination, as stated above, has been unfavorable. Secondly, 
The anatomical peculiarities in the relations of the vessel, to 
which may be attributed the possibility of the ligature on the 
outside of the scaleni. Thirdly, The rapidity with which the 
collateral circulation was restored, the pulse having been felt at 
the wrist twenty-four hours after the operation. Finally, The 
length of time the ligature remained attached, ninety-six days, 
notwithstanding all safe means were made use of to detach it. 

A lady, 30 years of age, of delicate constitution, had a con- 



430 ARTERIES AND YEINS. 

genital club-foot of the worst kind, and a double curvature of 
the spine. For the former of these she was treated, when young, 
by Dr. Brown, at his infirmary ; and the foot, after the section 
of the tendons, followed by the appropriate treatment, was com- 
pletely brought into its natural position,' so that she was enabled 
to walk with ease, without the aid of any mechanical support. 
The curvature of the spine was submitted to a similar treatment, 
with the same successful result. 

She consulted me in the early part of December, 1847, for 
an aneurismal tumor situated just above the scapular end of the 
clavicle, about the size of a pigeon's egg, of which she gave the 
following history : — 

Four months before, while in attendance on a sick brother, 
she had occasion to draw the cork from a bottle, and felt a sud- 
den crack over the clavicle. Her attention was not attracted 
to it at the moment ; but, a short time afterwards, a small swell- 
ing, having a decided pulsation, was distinguished at that spot, 
which increased rapidly in size. It had a powerful pulsation, 
and possessed the usual thrill characteristic of an aneurismal 
affection. 

I endeavored to discover the subclavian artery in its normal 
situation beneath the clavicle, at the point where it passes over 
the first rib. No large vessel, or any osseous protuberance an- 
swering to the tubercle of the first rib, usually taken as the 
guide to the artery in this position, could be found. Different 
parts of the neck were then explored, which led to the discovery 
of a large artery passing obliquely upwards, parallel to, and 
about an inch removed from, the external border of the trapezius 
muscle. Compression being made at this point, the pulsations 
of the tumor ceased, as well as the pulse at the wrist. There 
was no question, therefore, in my mind, that this was the sub- 
clavian artery ; but it was more difficult to determine the cause 
of this remarkable anomaly. 

I now sought for the first rib, and discovered both the first 
and a part of the second rib passing obliquely across the neck 
above the clavicle. The insertion of the scalenus anticus muscle 
into the first rib was at length distinguished : the tubercle, 
however, was not sufficiently developed to be manifest to the 



ANEURISMAL TIBIORS. 431 

touch. The whole osseous system of the chest, in this case, had 
undergone a partial displacement. The spine and ribs attached 
had been, as it were, moved upwards ; while the sternum was 
carried in an opposite direction. 

Making a strong compression on the vessel above the tumor, 
the arm became extremely painful, with a sensation of numbness ; 
and, on a subsequent and more careful examination, the whole 
brachial plexus of nerves could be discriminated, in immediate 
contact with the artery. 

As the tumor was rapidly increasing, it was evident, that, 
considering its situation and the great danger of delay, no time 
was to be lost, if any surgical operation was to be resorted to. 

The patient, a person of much fortitude and strength of char- 
acter, agreed at once to the course advised. The operation was 
performed on Dec. 24, 1847. 

An incision about two inches long was made, extending from 
near the outer and upper edge of the sterno-mastoid muscle 
downwards, in the direction of the scapulo-clavicular articula- 
tion, and an inch from the edge of the trapezius muscle ; the 
pulsations of the vessel being the principal guide, as the other 
anatomical marks were wanting. This incision divided the skin 
and superficial fascia ; a second cut opened one of the branches 
of an artery given off from the thyroid axis, which was tied. 
A nervous band of some size was now encountered, and at its 
side, and directly over the artery, a large vein, apparently the 
external jugular. The vein was carried to the upper part of 
the wound, with a silver hook, and the nerve to the lower ; the 
dragging upon the latter caused a disagreeable and somewhat 
painful sensation in the arm. 

The sheath of the vessel was next opened, the cellular mem- 
brane around it cleared away, and the aneurism needle, un- 
armed, passed from below upwards, on account of the difficulty 
of introducing it in the opposite direction, from the interference 
of the scalenus anticus, which had its insertion just below. The 
needle at once encountered and raised the lower nerve of the 
brachial plexus, which was in the most intimate contact with 
the artery. By depressing the handle, and urging the point 
forwards with careful manipulation, the eye of the needle was 



432 ARTERIES AND VEINS. 

brought out between the two. The instrument was now thread- 
ed with the ligature, and withdrawn. Careful exploration was 
made to ascertain if any nerve was included ; the painful sensa- 
tions in the arm, caused by drawing the ligature downwards, 
at first leading to the supposition that this might be the case. 
But, when the same traction was made directly upwards, no pain 
was felt ; the former sensations being produced by the dragging 
on the cervical portion of the brachial plexus, owing to their 
connection with the vessel. 

The ligature was now tied, and the wound dressed. The 
pulsations in the aneurismal sac, as well as those of the radial 
artery at the wrist, at once ceased ; and all appearance of tumor 
vanished. The patient's arm and hand were a little cold directly 
after the operation, but, being rolled in flannel, soon regained 
their natural temperature. 

25th. Found her quite comfortable. She had passed a 
quiet night. 

26th. She says that the pulse at the left wrist returned for 
a time last evening: it then disappeared, but returned again, 
though faintly, this morning. I could not discover it at the 
time of my visit. 

27th. She has been somewhat troubled by occasional pains 
in the arm. The pulse was felt yesterday once or twice, being 
intermittent. The wound has healed by the first intention. 
She has suiFered occasionally from palpitation of the heart. 

29th. The pulse was perceived, though feebly, at the wrist, 
but could not be detected in the axilla. The spot formerly 
occupied by the aneurismal tumor now presents an obvious 
depression. 

Jan. 2, 1848. — The pulse is constant at the wrist. 

14th. The ligature still remains on the artery, notwith- 
standing the traction daily made by the patient, in accordance 
with my directions. A number of large vessels, taking their 
origin from the subclavian, exist in different parts of the neck. 
One of these, apparently the supra-scapular, passes directly 
over the sac, and pulsates so strongly as at first to con- 
vey the impression of a return of pulsation in the aneurismal 
tumor. 



POPLITEAL ANEUKISM. 433 

March 30th. Once or twice in the course of the last two or 
three weeks, finding that the ligature was not detached, I have 
seized it with the forceps, and, holding the artery forcibly down 
on the rib, have twisted the thread with considerable force. 
This was done for the third time yesterday, when the ligature 
separated, ninety-six days after the operation. 

The wound almost at once closed. 

I saw this patient on Sept. 14, 1848, for the last time. At 
that period she was quite well, had recovered the use of her 
arm, and was in no way incommoded by the operation to which 
she had submitted. The aneurismal tumor had in a srreat meas- 

o 

ure disappeared ; but it still conveyed the impression of contain- 
ing a fluid. Directly on its surface, and incorporated with it, 
was a very large arterial trunk ; supposed, as above stated, to 
be the supra-scapular. This vessel pulsated powerfully, and at 
first gave an appearance of pulsation to the tumor, but, by 
careful manipulation, could be separated from it ; the pulse at 
the wrist still remained a little less strong than in the corre- 
sponding artery of the other side. 

Case CCLY. — Ligature of the Femoral Artery for Pop- 
liteal A.7ieurism. Cure. — In September, 1853, I was re- 
quested by Dr. Josiah Bartlett, of Concord, to see a man, a 
blacksmith by trade, with an aneurism of the popliteal artery. 
Four or five months before, he had perceived a small j)ulsat- 
ing tumor in the upper and back part of the left leg. This 
increased slowly to the size of a hen's egg. The knee was 
bent, and he was obliged to walk with a crutch. The foot was 
swollen, excessively painful, and its motions partially lost. 
The patient being informed of the dangers of the operation by 
ligature of the artery, the possibility of paralysis or slough- 
ing of the limb, consequent upon it, and of the alternative 
of the treatment by compression, decided on the former, as 
he lived out of Boston, could not well leave his family, and 
it was impossible to have the compression satisfactorily con- 
ducted at home. 

The femoral artery was therefore tied at the middle of the 
thigh, and the pulsation of the tumor at once arrested. The 

55 



434 ARTERIES AND VEINS. 

patient, a very muscular man, was directed to be kept in bed, 
artificial warmth to be applied if necessary ; and, in case of 
great re-action, blood to be taken from his arm. For a week 
or two after the operation, the numbness of the foot was much 
increased, though the pain was relieved. The ligature sepa- 
rated in sixteen days. 

This patient was seen by me some months afterwards, when 
he was able to walk. A small, hard tumor still existed at the 
place of the former aneurism, having an apparent pulsation, 
which, however, after repeated examinations, proved to arise 
and be communicated from an enlarged collateral vessel. He 
was directed to keep still, avoid animal food, and to do nothing 
that might excite the arterial action. 

By subsequent reports, he was quite well. 

Case CCLYI. — Large Ajieurism of the Thoracic Aorta, 
tuith Perforation of the Sternumi. Death. — A gentleman, 
'<)^ years old, was attacked in 1862 or 1863, with dyspnoea, 
attended with considerable cono-estion about the face, comino^ on 
suddenly, after mental emotion caused by the death of a friend. 
Being examined by his physician, strong pulsations were per- 
ceived in the neighborhood of the sternum ; and a pulsating 
tumor, with aneurismal thrill, was detected at about the middle 
of that bone. At this time, I saw him in consultation. 

The patient was of plethoric habit, had been generally 
healthy, but led a laborious life, being connected with a print- 
ing office, and up late at night. Some years before, he had 
had a rheumatic attack in his shoulders, lasting three months. 
I advised quiet, a vegetable diet, and great care as to exercise 
and excitement, until the course of the disease was fully de- 
veloped. Under this treatment, the thoracic symptoms were 
relieved, but the tumor gradually increased ; and he finally came 
under my care, with severe attacks of hemorrhage from the 
nose, which required surgical interference. 

In November, 1865, after having thus passed two or three 
years in comparative comfort by means of great care, he was 
suddenly taken, while absent from home, with faintness and 
insensibility, and was carried to his house. On seeing him, I 



ANEURISM OF AORTA. 435 

found the right side of the body paralyzed. His face was not 
red, as in apoplexy, but of a livid paleness. He gradually 
recovered his senses ; and, by the following morning, his mind 
was fully restored. The- attack was supposed to be caused by 
the escape of a coagula from the tumor, lodging in and obstruct- 
ing the vessels supplying one portion of the brain, and tempo- 
rarily suspending its functions. The paralysis of the leg and 
arm, which had been complete, gradually disappeared; so that, 
at the end of five or six weeks, nothinsf but a sliMit stiffness 
remained. At this time, the tumor on the sternum occupied 
nearly its entire breadth : it was thirteen inches in circumfer- 
ence, and had an elevation of between three and four inches. 
The parietes appeared bony for about half this distance ; though, 
on examination after death, this proved to have been decep- 
tive ; being above excessively thin, and apparently composed 
simply of the skin and the aneurismal sac. A slight ecchy- 
mosis had taken place on the surface. Pulsations in it were 
very active and powerful. 

Some change in the aneurismal tumor had produced an af- 
fection of the air-passages, so as, at times, almost to threaten 
suffocation. These symptoms, however, gradually subsided ; 
so that, at the end of a couple of months, the patient was in a 
comparatively comfortable state, able to walk about his room, 
and to take a moderate amount of food. 

On the 15th of January, 18 1) 6, early in the morning, at 
about four o'clock, he complained of a sudden pain in his right 
elbow, shoulder, and side of head, and almost immediately 
expired. 

On examination of the body the next day, the following 
were the appearances presented : — 

The sternal tumor had shrunken but little. In the left side 
of the chest, there was a quantity of bloody serum : in the ante- 
rior mediastinum was a large coagulum, enough to fill a quart 
measure. The pericardium was firmly adherent to the heart 
and parietes of the tumor. Through it, by a small rent half an 
inch in length, the blood had escaped. 

Neither the trachea, oesophagus, nor bones on the back part 
of the chest, appeared to be interfered with by the tumor ; the 



436 ARTERIES AND VEINS. 

irritation of the laryngeal nerve probably having a part in 
the laryngeal symptoms which were occasionally manifested. 

The aneurismal sac was as large as the two fists, and closely 
and extensively adherent to the anterior parietes. It arose from 
the ascending aorta towards the left side ; and the opening, 
which was of an oval form and remarkably defined, commenced 
one and a half inches above the aortic valves, and reached to 
within the same distance of the arteria innominata. It was 
evidently a false aneurism, and the cavity was nearly filled with 
soft fibrin and grumous coagula. 

There were also two other small aneurismal sacs, quite dis- 
tinct from the above. One was an inch from the aortic valves, 
and formed a very defined, rounded tumor upon the right 
side of the artery, of a dark-red color, firm to the feel from its 
being filled with coagula, and in size about equal to a nutmeg ; 
the other, arising from near the origin of the arteria innominata, 
was in every respect similar, except that it was more than twice 
as large. The orifice of each of these little sacs was of an 
oval form, quite small, and so defined as almost to look as if a 
piece had been punched out. 

The aorta, as fixr as where it was cut ofi" towards the dia- 
phragm, was quite diseased, with considerable cretaceous deposit. 
The ascending portion was very much dilated, and measured 
transversely about seven inches, without including the opening 
of the large sac. From the arch downwards, it was about the 
natural size. Upon the right side of the ascending portion, and 
commencing two Inches above the valves, was a " true " aneu- 
rism, the cavity of which was shallow, but sufficiently defined, 
and measured one and a half inches in diameter. This, of 
course, was not included in the above measurement. There 
was also a defined dilatation of the arteria innominata, at its 
origin and In its whole circumference, extending upwards about 
three-fourths of an inch. 

The heart was healthy, with the exception of the adhesions 
mentioned above. The upper vena cava was completely obliter- 
ated within an inch of its opening into the auricle, and to the 
extent of three-fourths of an inch ; nothing being seen of the vena 
azygos. 



ANEURISM OF AORTA. 437 

The sternum was entirely destroyed from just below the carti- 
lage of the second rib to opposite that of the fifth ; and, the co- 
agula having been removed, the ragged ends of the cartilages 
were distinctly felt within the sac. 

Case CCLVII. — Enormous Aneurism of the Abdominal 
Aorta. Death. Autopsy. — I was first called to the patient, 
a gentleman 43 years old, in 1840. He was afilicted with 
severe neuralgic pain in the left hypochondriac region, ex- 
tending in different directions to the bladder, kidneys, and also 
downwards to the inte2:uments of the left thio-h, where it was 
almost insupportable. At that time, no tumor could be dis- 
covered in the abdomen. The suffering, in spite of all reme- 
dies, became so severe, that the patient, in order to get any 
relief, was obliged to place himself on his hands and knees ; and, 
thus situated, with his head downwards, he was able to get some 
rest in the course of the twenty-four hours. This position was 
maintained, for the greater portion of the time, for six weeks. 
At the end of that period, he was seized with a violent hemor- 
rhage from the nose, which was only checked, at the end of 
twenty-four hours, by plugging the nostrils. Subsequent to the 
hemorrhage, the pains became somewhat relieved ; and he was 
able to resume the recumbent position. An examination of the 
abdomen being now possible, a pulsating tumor could be dis- 
covered in the left hypochondriac region, having on its front 
part what appeared to be the kidney. 

From that period till 1842, the tumor gradually increased in 
size, extending in either direction, upwards towards the thorax, 
and downwards towards the thigh. The pulsations were usually 
so strong as to shake the whole body, and were much in- 
creased before an occurrence of hemorrhage from the nose, 
which, from 1840 to 1842, occurred at pretty regular in- 
tervals of two or three months, and was always checked with 
great difficulty, but was attended with relief to the system. The 
digestive functions were pretty regularly performed. He was 
obliged to take his food while in a recumbent position ; other- 
wise the tumor seemed to press upon the stomach, and destroy 
the appetite. As the tumor encroached on the thigh, the limb 



438 AETERIES AXD TEEN'S. 

gradually became more and more flexed, until it was drawn up 
so as to form a right angle with the body. 

July 11, 1842, he was again seized with a return of hemor- 
rhage from the nose, which, though checked from time to time, 
again returned so as gradually to exhaust him. The nostrils 
were plugged both behind and before : the blood, however, 
was in such a fluid state that it still continued to find an exit 
through the puncta lachrymalia. 

The patient retained his faculties perfectly to the last ; and, 
through the whole of this long and trying period, bore his 
suflTerings with the most heroic fortitude. 

The treatment consisted principally in small bleedings, when 
the system from time to time became plethoric, and intimations 
were given of a recurrence of the hemorrhage. By these 
means, the epistaxis was occasionally warded ofi". The patient 
himself was always well aware when this became necessary. 

The following appearances were presented at the post-mortem 
examination : On turning back the abdominal parieties, all the 
organs of the left side were found to be raised up on the surface 
of an enormous tumor. The left kidney occupied the epigastric 
region, and was the most prominent organ. 

The tumor had pushed up the diaphragm, so as to be, at its 
apex, on a level with the fourth or fifth rib ; below, it had 
passed down on the surface of the psoas and iliac muscles, 
underneath the crural arch, and descended nearly to the middle 
of the thigh. On removal from its situation, it was found to 
commence in the abdominal aorta, opposite to the origin of the 
coeliac axis. The superior parietes of the artery appeared in- 
tact ; below, at the point of origin of the tumor, they were 
deficient for the space of two inches. 

The parietes of the tumor were formed beneath by the ribs, the 
muscles, and the integuments of the posterior part of the abdo- 
men ; above, the usual appearance presented by an aneurismal 
sac. The bodies of the lower dorsal, and three superior lumbar 
vertebrae, were nearly destroyed ; also a portion of the body and 
crista of the ilium of the left side. One large coagulum ap- 
peared in the sac. The blood was in a very fluid state, so that 
nearly all which remained in the body seemed to escape with the 



LIGATURE OF CAROTID. 439 

first incisions. The tumor was nineteen inches in length, and 
eighteen in circumference ; being, I believe, one of the largest 
on record. 

Case CCLVIII. — Wound of the Carotid Artery. Liga- 
ture twice repeated. Death from Hemorrhage from the Recur- 
rent Circidation. — Early in the spring of 1848, while a young 
man, 18 years old, was walking in the street, a person stabbed 
him from behind in the neck. The wound bled freely at the 
time, and again on the two subsequent days ; the bleeding each 
time being arrested by exposure to the air, and compression. 
The cartilage of the left ear was divided ; and the weapon had 
penetrated the neck behind the angle of the lower jaw, and 
about half an inch behind and below the left ear, in a direction 
downwards, inwards, and forwards. When I saw him, a week 
after, he was very pale, and somewhat emaciated ; his pulse was 
quick and jerking ; there was slight paralysis -of the left side of 
the face. I tied the left common carotid in the usual manner. 
From the seventh to the ninth day, repeated hemorrhages oc- 
curred, each time being checked by compression. On the ninth 
day, the wound was opened, and cleaned out ; when it was found 
that the blood came from the carotid artery, where the ligature 
had been applied. On consultation, the artery was again tied 
below the former place. Two days after this, the blood began 
to flow from the upper part of the wound, apparently coming 
from the spot where the first ligature was applied, and from the 
recurrent circulation. Pressure arrested the flow of blood, 
which recurred, however, in the course of the day. Coma 
supervened in the course of three days ; respiration gradually 
became more feeble ; and, on the thirteenth day after the first 
operation, he expired. 

At the autopsy, it was found that the wound in the neck was 
irregularly triangular, situated as mentioned above, and pene- 
trated beyond the carotid. The lower jaw was sawn through, 
and the left side disarticulated. The wound was then followed : 
it divided the mastoid process of the temporal bone, nearly 
parallel with the base of the skull ; a portion about half an inch 
thick being separated. It then passed inward, upward, and for- 



440 ARTERIES AND VEINS. 

ward, in front of the styloid process of the temporal bone 
and the internal carotid artery to the depth of about two and a 
half inches, in the direction of the anterior portion of the base 
of the brain ; and stopped very near, if not in contact with, the 
skull, close to the inner extremity of the petrous portion of the 
temporal bone. About two inches from the commencement of 
the wound, a cavity nearly as large as an almond had been 
formed by the force of the blood issuing from an artery, the 
open mouth of which was found just beyond. The whole of 
the left side of the neck was much swollen. There were no 
healthy granulations in the wound made for the purpose of ty- 
ing the carotid. The ends of that vessel, where it had been 
divided by the first ligature, were separated about half an inch. 
The second ligature still surrounded the artery, which was filled 
below with coagula of little density. 

The whole of the brain was pale, bloodless, and very soft. 
A layer of lymph covered its base, extending from the middle 
of the fissure of Sylvius on one side to a corresponding point 
on the other, and from the middle of the anterior lobes, back- 
wards and downwards nearly to the foramen magnum. 

The heart was contracted, nearly empty, and its muscular 
substance loose and flabby. 

The left lung was adherent to the costal pleura by strong 
adhesions. The organs generally presented a bloodless appear- 
ance. 

Case CCLIX. — Woimd of Superficial Palmar Arch. 
Ligature twice supplied. — March 31, 1861. A woman, 18 
years of age, received a wound in the palm of the hand by 
thrusting it through a pane of glass while trying to prevent a 
window from falling. There was a good deal of bleeding at 
the time, but it was arrested by compression. April 1st, there 
was a return of the hemorrhage ; and she bled, according to the 
account of her friends, "two quarts." She was then brought to 
the Hospital. On her entrance, she was very weak, and faint. 
There was a pulsating tumor in the palm of the hand, with a 
small wound over it. Compression of the radial artery had no 
effect upon it ; but the pulsations were at once arrested by 



VASCULAR OR ERECTILE TUIVIOR. 441 

compressing the ulnar artery. It was decided to secure the ar- 
tery in the wound. She was etherized ; and, the wound being 
enlarged, the superficial palmar arch was exposed, and the 
source of the bleeding at once discovered. The artery was tied, 
and the wound closed. She was ordered beef-tea, and brandy 
and water. On the following day, the 2d, there was an oozing 
of blood from the wound ; and compression was applied. 

On the 4th, quite a hemorrhage occurred ; and, on sponging 
the wound, the ligature applied before became loose, and 
came away. The wound was opened, and the same vessel tied. 
She was discharged on the 23d, well. The second bleeding in 
this case, in all probability, was occasioned by the arch having 
been raised up, and the ligature applied to the loop ; the force 
of the circulation gradually pressing the ligature off. At the 
time, it seemed to have been tied with ordinary force. On a 
second application in the same way, the result was successful. 

In recent cases of this kind, it is best to search for the vessel, 
and tie it, if possible, in the wound ; otherwise, try pressure. 
If this falls, tie the brachial artery, although this is not always 
certain ; as, in one instance I have seen, the hemorrhage re- 
curred after this vessel was supposed to be tied, on account of 
its division higher up. 



YASCULAR OR ERECTILE TUMOR. 

This disease has been admirably described and depicted by 
John Bell, who named it aneurism by anastomosis. The name, 
erectile tumor, is given to it on account of the striking analogy 
which it presents in structure with the erectile tissue found in 
certain parts of the body in man, and in most of the higher 
animals. Erectile tumors are made up almost wholly of great- 
ly enlarged bloodvessels ; and are divided into arterial and 
venous, according as one or the other class of vessels seems to 
predominate. The arterial tumors, which are altogether the 
most formidable, are often of very rapid growth, and are marked 
by active pulsation. The venous tumors are more indolent, 
and often impart to the touch the feeling of a fatty growth : 
they may, however, be partially emptied of blood by pressure, 

56 



442 AETERIES AND VEINS. 

and thus temporarily reduced in size. It is a common charac- 
teristic of erectile growths, that they become enlarged and 
turgid during any act which obstructs the free return of the blood 
to the heart, — such as coughing, crying, laughing, &c. ; con- 
tracting again to their former size when the patient becomes 
quiet. 

The treatment of small erectile tumors — neevi materni, for 
instance, — is very simple, and may be either by excision or by 
the ligature. In excising them, the absolute rule is that laid 
down by John Bell, — " not to cut into them, but to cut them 
out." In operating by the ligature, it is essential that the whole 
growth should be thoroughly strangulated. If, in the attempt 
to excise the tumor, it is unfortunately cut, the whole growth 
should be immediately included in a ligature, and allowed to 
come away by sloughing. I have several times treated erec- 
tile tumors of the face by repeated small cauterizations with 
nitric acid, and have thus succeeded in destroying the whole 
morbid tissue piecemeal, without the loss of substance and con- 
sequent scar which follows excision or the ligature. Injection 
of the growth with perchloride of iron has also been employed, 
in many cases with success ; but death has occasionally resulted 
from the practice. 

The operation for the cure of extensive disease of this kind is 
one of the most formidable in surgery, owing to the liability to 
dangerous or even fatal hemorrhage. In two cases, where large 
pulsating tumors occupied nearly the whole forehead and upper 
part of the head, I have succeeded in destroying them by a 
series of operations, in which the afferent vessels were obliter- 
ated by strong ligatures tied over pins passed beneath them, and 
thus the whole circumference of the growth thoroughly strangu- 
lated. By the application of new ligatures as often as any 
return of the pulsation w^as detected, and by the free use of 
styptics and escharotics, the disease was finally extirpated. In 
another case, I tied both the carotid arteries for an immense 
erectile growth, which occupied the lower lip and a large part of 
the face and neck. The result of this operation, which was then 
only the third or fourth in which both the carotid arteries had 
been successfully tied, was perfectly satisfactory. A part of the 



VASCULAR OR ERECTILE TUMOR. 443 

lower lip, which had been the seat of an ulcerated and a bleed- 
ing tumor, was afterwards excised without troublesome hemor- 
rhage ; and, on seeing the patient two years subsequently, the 
vascular tissue was found to have wholly disappeared. In a 
pulsating tumor of this character, occupying the palm of the 
hand, and held, as it were, like a ball in its grasp, the tumor 
gradually increased, and finally involved nearly the whole upper 
extremity. The limb was amputated near the shoulder, in time 
to save the life of the patient ; although the erectile tissue had 
partially invaded the structure of the part, and many ligatures 
were required to arrest the bleeding. The specimen, which 
shows a direct continuity of the largely dilated arteries with 
the venous trunks, was beautifully injected and prepared by 
Dr. R. M. Hodges. I have also had under my care a girl, 
nineteen years of age, with a large venous erectile tumor, occu- 
pying nearly half the cavity of the mouth, and hanging down 
from the lower lip. It also included a large portion of the 
tongue, and at times seriously affected deglutition and respiration. 
This case was operated on by the ligature, tying both the tumor 
of the cheek and that of the tongue on the same day. The 
ligatures came away at the proper time, and the result was fully 
successful. 

I have spoken thus at length of this disease, on account of its 
rarity, and from the fact, that, owing to the absence of pain, it 
is too often neglected until it has acquired enormous proportions. 
In such cases, it is rarely to be cured by a single operation ; but 
requires a patient and persevering use of needles, ligatures, 
caustics, and sometimes, although very rarely, the knife, before 
it can be completely extirpated. 

Case CCLX. — Formidable Case of ^^ A.neurism by Anas- 
tomosis " of the Scalp. Operation by Ligature. Cure. — 
A healthy young man, 19 years old, entered the Hospital on 
the fifteenth day of April, 1861, for the treatment of a tumor 
of the scalp, which had begun to grow with great rapidity. 

About five years before, it was noticed that the bloodvessels 
under the skin of the forehead were becoming enlarged ; but it 
was only for about a year that a decided tumor had existed. 



444 ARTERIES AND VEINS. 

The tumor was situated in the median line, and measured 
in its longest diameter about three inches, and in its smallest 
nearly two ; its elevation being about two inches above the 
frontal bone. Its shape was irregular ; its bulk, about that of 
half a large orange ; its appearance, that of a large mass of 
earthworms enclosed in a sack. It was of a reddish color, soft 
and compressible, and liad a pulsation synchronous with that 
at the wrist. It was supplied by a great number of large, tor- 
tuous vessels, which pulsated strongly. The temporal and 
frontal arteries in front, and the occipital artery behind, seemed 
to aiFord the chief supply of blood to the tumor. The frontal 
arteries were especially enlarged, being quite equal in size to the 
radial artery. The patient had tried compression for six weeks, 
without diminishing the size of the tumor or the pulsation in 
it. All the vessels in the neighborhood of the tumor were 
greatly enlarged, and the whole surrounding tissue had that 
aneurismal thrill which belongs to affections of this description. 
It seemed to be spreading gradually, and involving the whole 
thickness of the scalp on the top of the head. The attack of it, 
therefore, by ligature of the large vessels, appeared to be at first 
of somewhat uncertain promise. 

Operation. — On the 17th of April (the patient being ether- 
ized) , by means of curved needles a strong ligature was intro- 
duced under each large vessel supplying the tumor, and at as 
great a distance as possible from the erectile tissue composing it. 
The ligatures were tied as tightly as possible, including the 
skin. The effect of this was to diminish the pulsation in 
the tumor, but not entirely to check it. Inside this circle, 
three needles were therefore introduced under the skin, each 
about three inches long, so as to include all the tissue around 
the tumor. Ligatures were introduced beneath these needles, 
and firmly tied. This served to cut ofi" the circulation between 
the tumor and the surrounding tissues. There still remained a 
sensation of vascular motion in the substance of the tumor. 
Two strong ligatures were therefore passed through the base of 
this last circle, and were brought over the summit of the tumor, 
and firmly tied. The operation occupied about an hour and a 
quarter. In the evening, the patient was quiet, and slept a good 



VASCULAR OR ERECTILE TIBIOR. 445 

part of the time : his pulse was 70. On the 18th, he had some 
headache, and was much inclined to sleep ; skin hot, pulse 82. 
There was no pulsation in the tumor, and small vesications were 
appearing on its surface. On the 19th, he was comfortable ; 
pulse, skin, and tongue natural; bowels had moved without 
medicine ; appetite fair, and no unpleasant symptoms. On the 
23d, patient had remained comfortable since last report ; was sit- 
ting up in bed. There was a slight serous discharge by the side 
of the needles. On the 24th, there was a swelling of the right 
parotid gland, and a glossy appearance of the tissues between it 
and the tumor. Water-dressings were applied over the whole 
surface. On the 27th, a ligature and a needle were removed. 
29th. It was found that a part of the tumor included between 
the ligatures was still alive ; but no pulsation could be detected 
in it. On the 2d of May, I removed all the sutures and a por- 
tion of the slough, which was partially detached. On the 11th 
of May, the patient was again etherized, and two large needles 
passed, at right angles to each other, under the base of that 
portion of the tumor which remained alive. A large and strong 
ligature was then passed under them, and tied with great 
force. On the 15th of May, the patient having gone on well, 
and the tumor being quite loose, the needles were withdrawn. A 
thick silk ligature was passed around the base of the tumor, and 
tied with a jerk, cutting off its remaining attachments, and com- 
pletely separating all the diseased tissue. This was followed by 
quite free bleeding, requiring the application of ligatures to one 
or two large arteries. The bleeding which occurred from the 
small vessels w^as checked by the use of a solution of perchloride 
of iron. On the 25th of May, the eschar formed by the last 
application separated, leaving a healthy granulating surface. 
This healed kindly. Some weeks later, there being a suspicion 
of a slight erectile tissue remaining in a portion of the skin, I 
excised it, which finished the cure. 

This case is interesting, first, from the large size of the erec- 
tile tumor ; secondly, from the great calibre of the principal 
vessels which supplied it ; and, thirdly, from the immunity from 
unhealthy action in the skin, notwithstanding the great amount 
of that tissue implicated in the ligatures. The parotid gland, at 



446 ARTERIES AND VEINS. 

one time, was certainly irritated, and the straining of the whole 
scalp caused a certain amount of swelling and an approach to 
oedema ; but there was never any thing like erythema, and but 
little constitutional disturbance. There is but little doubt, that, 
if the tumor had gone on much longer unchecked, the vascular 
system of the scalp would have become so implicated as to make 
any attempt to relieve the patient by operation unavailing. 

Case CCLXI. — Ligature of both Carotid Arteries foi- 
a remarkable Erectile Tumor of the Mouthy Face^ and 
JSFeclc. — A young man, 23 years of age, consulted me on 
Oct. 1, 1845, for an enormous tumor of the lower lip and 
tongue, which had supervened on a birth-mark occupying a 
good part of the face and neck, and presented the folio win o- 
appearances : — 

The head of the patient was larger than common : the left 
side of the face was almost wholly occupied by a discoloration, 
which was originally less extensive and lighter colored, but had 
attained the extent and appearance above mentioned. The 
right side presented a discoloration about half the extent of the 
left. The lower lip was much enlarged, everted, and gave three 
aspects : externally, the thick tumefied lip ; internally, a fungoid 
tumor, covered by red granulations distended by blood, as if 
ready to break through ; the whole surmounted by an irregular 
ulceration with thickened edges and a hardened base. The red 
granular appearance extended underneath the tongue to the infe- 
rior surface, the left half of which was enlarged to double its 
natural size and partially protruded between the teeth ; its upper 
portion being the seat of five or six small ulcerations. The dis- 
coloration of the face also extended on the outside of the lip 
downwards over the chin and neck, covering a space of seven 
or eight inches in diameter ; the whole, especially that on the 
face, being rather more full and distended with blood than 
natural. (See Plate III.) 

The history of the case was this : The mark, as above stated, 
was congenital. About 1841 the lip and tongue began gradu- 
ally to swell, and the former very shortly ulcerated. The 
ulceration occasionally healed, until the last year, when the 



in. 




VASCULAR OR ERECTILE TUMOR. 447 

enlargement became permanent. By compression, the blood 
could be entirely expelled from the lip, and in the same manner 
from the tongue. Since the erectile tissue had been developed 
in the lip, the discoloration of the face had become more marked, 
had extended, and evidently partook of the character of the 
erectile tumor in its neighborhood. 

This case was a very critical one ; and the two most prominent 
dangers which threatened him were these : First, a possible 
degeneration of the ulcerated lip ; and, secondly, alarming 
hemorrhage, which was likely sooner or later to take place, 
and which must, in all probability, prove rapidly fatal. 

The following is the course I proposed to him : First, to have 
the left carotid artery tied ; Second, after a considerable inter- 
val of time to tie the right carotid ; Third, to attack what- 
ever portion of the tumor remained by means calculated to pro- 
duce contraction of the vessels and obliteration of the erectile 
tissue. 

To this course, after weighing well all the dangers connected 
with it, the patient agreed; and, on Oct. 5th, I tied the left 
carotid artery. He recovered from the operation, and was out 
in about ten days. At that time the face had become more 
pale, the erectile tissue and the large tumor of the lip much 
diminished in size, and the painful ulceration which surmounted 
It was rapidly healing. He seemed to be in perfect health. I 
advised him to go home, remain three or four weeks, and then 
return to have the other carotid tied. 

He returned Xov. 7th, wdien the tumor of the lip was found 
to have diminished one-half. The fulness of the face and neck 
was less, and the discolored parts were much paler than when 
he left. Tlie size of the tongue was less, and the ulcerated spots 
on it had quite healed. His health remained good. It was 
determined, therefore, to proceed at once to the ligature of the 
carotid of the right side. 

The patient being placed in a sitting posture, the carotid 
artery was laid bare, and a ligature passed under it. It was 
dilated about one-third more than its natural size. He was 
then placed on his bed, with the head slightly elevated : the 
pulse was found to be 80 in the minute. The ligature was 



448 ARTERIES AND VEINS. 

drawn tight. At first he exhibited no change ; but, shortly after, 
the pulse appeared to labor, and became slightly irregular : the 
only symptom noticed in the patient was that he became drowsy. 
After waiting about fifteen minutes, the second knot was tied, 
and the wound dressed. 

No inconvenience was experienced from this operation, farther 
than a slight faintness during the afternoon on attempting to 
raise his head. He was directed to keep perfectly quiet, and to 
maintain strictly the horizontal position. 

On the third day, there was a slight soreness about the larynx, 
which lasted three days. Nov. 19th, at the end of ten days, he 
was in good health, and able to go down stairs. The face was 
much paler than before the last operation, and the morbid 
appearances were diminishing. 

Nov. 26th. The ulceration of the lip was quite healed; but 
the lip itself was still thick, and somewhat everted by the erectile 
tissue, which entered into its whole substance. 

It was concluded, that, although the swelling was gradually 
diminishing, yet it would not wholly disappear without a further 
operation ; and that, as the patient lived at a considerable dis- 
tance, the disease, if disposed to return, might get beyond 
control before the proper means could be applied to check its 
increase. I therefore determined to remove the diseased portion 
of the lower lip. Previously to this, and in order to avoid hem- 
orrhage, I performed the following operations : — 

A cataract needle was plunged into the vascular texture on the 
left side, and carried in different directions, so as to break up 
and destroy its organization. No hemorrhage followed this 
application. Three days afterwards, a similar operation was 
repeated on the right side. 

Nov. 29th. A final operation was performed. A strong 
compression being exercised, by means of two steel forceps pre- 
pared for the purpose, on each side of the lip, so as completely 
to interrupt the course of blood into it, a portion not less than 
two inches in length at its free edge was removed by a triangular 
incision. At first there was not the slightest hemorrhage, the 
two lips of the wound remaining perfectly dry : on the com- 
pression being removed, however, blood gradually oozed from 



IV 




€■ 



VASCULAR OR ERECTILE TUMOR. 449 

the whole cut surface. This was easily checked, and the edges 
of the wound approximated by a number of points of the inter- 
rupted suture, and a powerful compressing bandage applied. 

For the first twenty-four hours, he was carefully watched. 
Towards evening, a coagulum was found projecting from the 
wound, which was removed. From this time, there was no 
farther hemorrhage or bad symptom ; and the wound healed by 
the first intention. 

The portion of lip removed presented a spongy tissue, like the 
body of a leech, and gave a sensation in cutting like a piece of 
diseased lung : parts of it were indurated from the previous sub- 
cutaneous incisions. The muscular tissue had almost completely 
disappeared. 

On Dec. 12th, the patient returned home quite well. 

At this time, the drawing, Plate FV^., was made. As will be 
seen, the discoloration of the face had become much paler, and 
that of the neck and chest had almost wholly disappeared. The 
ear had lost its swollen and deep-reddish color, and had become 
of a natural size and of a pale aspect. 

No pulsation could be discovered in either of the temporal 
arteries, or, in fact, in any of the arteries of the head. In the 
neck, just above the clavicle, two large arteries, nearly the size 
of the carotids, were seen pulsating powerfully under the skin ; 
being, in all probability, the supra-scapular arteries greatly 
enlarged. 

Remarks. — It is now rather more than sixty years since Sir 
Astley Cooper first applied a ligature to the carotid artery for 
aneurism ; and the operation at that time was looked upon with 
gi'eat distrust, from the fear of a fatal disturbance to the functions 
of the brain. It has since been frequently repeated, and with 
as good success as perhaps any of the gi-eater operations in 
surgery. The object appears to be, that sufficient time should 
elapse between the ligature of the carotids to allow the collateral 
vessels which supply the brain to be dilated, so as to carry the 
quantity of blood required for the performance of its functions. 

It seemed probable that hemorrhage would seal the patient's 
fate, or the morbid degeneration of tissue would hasten his 
death, unless some sure and active means were adopted to arrest 

57 



450 AETERIES AND VEINS. 

the disease. If the disease had been situated at a great distance 
from the vessels to be ligated, on the scalp for instance, there 
would have been a question, whether the supply of blood might 
not be kept up hj a collateral supply through the vertebral 
arteries, by means of the ophthalmic. In the present case, no 
danger of this kind was likely to give cause for immediate 
apprehension, and the active part of the disease might easily be 
extirpated before the anastomosing vessels from other quarters 
had begun to supply the tumor, — an opinion supported by the 
event. The attempt to remove the lip without the ligature of the 
carotids would probably have been attended with fatal hemor- 
rhage ; and, even if the patient had escaped this accident, the 
diseased tissue in the neighborhood would have been an objection. 

This patient I had an opportunity of seeing three years after- 
wards, and of making some observations on the state of the 
circulation in those parts about the face and neck supplied by 
the carotids. The situation of the temporal arteries being ex- 
plored, no appearance of pulsation in them could be discovered. 
The same was found to be true in regard to the labial arte- 
ries. The angular arteries, where they inosculate with the nasal 
branch of the ophthalmic, gave the faintest pulsatory motion. 
In the region of the neck were a number of large vessels, having 
their origin from the subclavian ; among which the supra-scapular 
was chiefly to be distinguished. The lip was rather more full 
in appearance than when the report of the case was made, but 
free from ulceration. The functions of the brain had not in any 
way been disturbed. 

I have, however, twice attempted this operation in aneurism 
by anastomosis of the upper lip, where the disease has been 
partial. One of these cases is described in Dr. J. C. Warren's 
work on Tumors. The individual had a large red mark occu- 
pying nearly one-half of the left side of the face. During his 
childhood, the upper lip on that side had enlarged until it formed 
a permanent tumor, hanging down and obscuring the under lip : 
the gums had partaken of the disease ; had become spongy, and, 
with the rest of the diseased mass, were bleeding on the least 
injury. Rather more than half of the upper lip was affected. 
I removed the whole of this by means of two incisions made in 



VASCULAR OR ERECTILE TUMOR. 451 

the adjoining sound textures. A triangular piece being thus 
included, a number of dilated vessels, which su23plied the erectile 
tissue, were tied ; and the only hemorrhage which was trouble- 
some arose from the angle of the wound, where the disease had 
extended up into the nostrils. The inflammation supervening 
on this operation was sufficient to obliterate the morbid tissue, 
which pervaded the mouth and its neighborhood. Three months 
afterwards, I saw almost exactly a similar case of disease (on the 
right side of the face) , which was successfully treated in the 
same manner. 

Case CCLXII. — A^neurism by A.nastomosis successfully 
treated by Various Operations. — The subject of this case was 
an inhabitant of Nova Scotia, a healthy man, 33 years old. He 
had on his forehead, principally below the roots of the hair, a 
little to the right of the median line, a soft, pulsating, irregular 
tumor, about three inches in diameter, and from a half to three- 
fourths of an inch in thickness, which gave him a very formid- 
able aspect. 

This tumor was of a reddish color, becoming redder and 
larger when the patient was excited, either by bodily exercise 
or mental disturbance. It appeared to consist of coils of vessels. 
It was easily compressed, and, on removal of the pressure, im- 
mediately enlarged again. A number of pulsating bloodvessels 
were seen to enter it from different directions, principally on the 
right side. Of these might be distinguished, first, the temporal 
artery, which was in a very enlarged and tortuous state as far 
down as the lower part of the external ear ; second, a branch 
of the frontal artery ; third, the facial or angular artery, from 
the internal commissure of the eyelids. On the left side were 
seen the left temporal artery, which was nearly as large as 
the right, and the left facial artery, which, with its fellow, the 
artery of the right side, and its accompanying veins, formed a 
vascular tumor at the root of the nose. The veins themselves 
were of an enormous size, passing down from the tumor on 
either side of the nose, coverino' and partially obscuring the 
internal commissure of the eyelids. Besides these vessels, the 
whole scalp in the neighborhood of the tumor seemed alive with 



452 ARTERIES AND VEINS. 

smaller arterial trunks, which were seen pulsating in every 
direction. 

On compressing the temporal arteries, pulsation in the tumor 
was much weakened ; and when, in addition to these, the facial 
arteries were also compressed, pulsation ceased, and the tumor 
became flaccid. 

This tumor began sixteen years before, without any known 
cause, by a small reddish spot on the right side of the forehead. 
There was an occasional throbbing of the carotid arteries, par- 
ticularly that of the right side. The patient was also subject to 
distressing headaches, accompanied with increased action of the 
bloodvessels of the tumor and of the head generally. This 
vibratory action of the arterial system of the head, neck, and 
upper extremities, was quite remarkable. He was incapacitated 
by it from all active exertion, and was ready to undergo any 
operation that promised to relieve him. 

The course of this tumor, if not arrested by surgical treat- 
ment, could be readily foreseen. The morbid action would 
gradually involve other vessels, until the whole scalp became 
filled with enlarged arteries. The vessels of the eyelids, of the 
face generally, and even of the interior of the mouth, were likely 
to be involved. The patient's condition would, in this way, 
become almost insupportable ; and his life would perhaps be 
hazarded by the rupture of the tumor, which seemed almost 
ready to take place. 

What means should be adopted to arrest its progress ? Those 
which naturally presented themselves in the first place were of 
two descriptions ; First, ligature of the carotid artery. But, in 
this case, the ligature of a single carotid might not suffice to 
arrest the flow of blood into the tumor ; since the vessels which 
supplied it, although principally from the right, were partly 
from the left carotid. The ligature of both carotids would there- 
fore be necessary : but the result was less likely to be successful 
than in the preceding case, on account of the greater distance of 
the tumor from the arteries tied, and from the probability of its 
having other means of supply through the vertebral arteries, 
which inosculate freely with the branches of the internal carotid ; 
the ophthalmic in this case being unusually dilated. The second 



VASCULAR OR ERECTILE TTBIOR. 453 

mode of operating which suggested itself was to expose the differ- 
ent vessels supplying the tumor, and pass a ligature under 
them. The objection to this course was the length of time 
an operation upon so many vessels would require. Were 
there any means that could be devised other than these two? 
The tumor was much too large -to admit the safe and effectual 
application of caustic. It could not be cut out without danger- 
ous hemorrhage. It was too large, and too much connected with 
the bone, to admit the application of ligature en masse. 

Oct. 31, 1845. Having compressed, on the right side, the 
frontal and the two temporo-parietal arteries, and on the left 
side the continuation of the temporal artery through the frontal 
region, and the temporo-parietal, the pulsations of the tumor 
appeared to be arrested ; and its contents were readily expelled 
through the large veins, running into the facial vein. It was 
determined, therefore, to interrupt the circulation through the 
five vessels first mentioned ; three on the right side, and two on 
the left. Instead of exposing and taking up these vessels in the 
usual way, they were compressed by a ligature, thrown over 
the needles passed under them, in the form of a figure of 8. 
After this, the pulsation of the tumor was much diminished. 
Yenesection was then performed, and the patient placed in bed 
with his head elevated. 

Nov. 6th. The needles were removed. Yery slight soreness 
had been experienced from them. The tumor was diminishing 
in size ; the vessels constituting it appeared more flaccid and 
compressible. The soreness and all the uncomfortable sensations 
connected with it were lessened. 

12th. The pulsations in the right and left temporal arteries 
still continuing, a needle was passed under each of these, directly 
above the ear ; after which the pulsation subsided, and also the 
general sense of beating about the head. The patient was much 
more comfortable. 

21st. In consequence of a slight bleeding from the wound of 
a pin inserted on the 16th, it was thought best to obstruct the 
vessels on the anterior and on the internal part of the tumor ; 
and pins were passed in each of these situations. There was 
then no pulsation in the tumor ; the tenderness existing on the 



454 ARTERIES AND VEINS. 

upper part before any operation had been increased. He had a 
chill from ofoino^ into another room in the house, and after that 
some fever. 

2 2d. At this date there was a sudden rupture of the tumor, 
attended with considerable hemorrhage. Being hastily called to 
the patient, I passed two large pins, at right angles with each 
other, under that part of the tumor from which the hemorrhage 
was taking place. A ligature was carried around under the 
needles, and, being tightened, the bleeding was eiFectually 
checked. It was to be feared, however, that, as the pins ulcer- 
ated out, the hemorrhage would recur. There being a want of 
accommodation in his lodging, and in order that he might be 
more carefully watched in case of a second rupture of the tumor, 
he was advised to go to the Hospital, where he came exclusively 
under the care of Dr. John C. Warren, to whom I am indebted 
for the remaining history of the case. 

25th. "The pulse was now natural, 75 ; the internal sensa- 
tions were much improved ; there was no vibratory motion of 
the arteries of the head, and none were discoverable in the tumor, 
though a pulsation still existed. A slight oedema extended from 
the tumor to the nose and eyelids. Occasionally a drop of 
blood started from the needle wounds. From time to time, 
leeches have been applied with great relief. 

30th. " On this day, a vessel was discovered running from 
the left frontal artery across the left eyebrow, communicating 
with a branch in the angle of the eye on the right side, 
thence running up along the left edge of the tumor, till it 
reached its superior posterior border. It did not produce a pul- 
sation in this part of the tumor ; but skirting along its edge for 
some distance, as it did, there was a strong probability of its 
sending vessels into the mass, thus tending to keep up the 
morbid action. The needles which were inserted on the 2 2d 
inst. caused an inflammation and induration of the tissue in 
their neighborhood, and were removed without hemorrhage. 

" As compression of the artery rising on the forehead checked 
the specified pulsation, it was determined to tie this vessel. A 
needle was accordingly passed under it on Dec. 1st. Before 
placing the ligature, the vessel was compressed on the needle, 



VASCULAR OR ERECTILE TUMOR. 455 

without interrupting the pulsation along the edge of the tumor. 
Another needle was therefore passed under that part of the 
artery where it penetrated at the superior internal angle of the 
tumor, embracing, over the needle, a vascular substance at least 
half an inch wide. A ligature, passed in the figure of 8 over 
this needle, suspended all pulsation. The patient had some 
pain, which lasted a couple of hours ; after which he became 
easy. 

Dec. 3d. " Two needles had separated from the substance of 
the tumor without hemorrhage. Besides the needle passed on 
Dec. 1st, there still remained one needle at the lower part of 
the tumor, which was passed under an artery from the right 
frontal. The tumor, which had been hard from inflammation, was 
softened ; its heat, except near the needle passed the last time, 
had subsided. There was no throbbing in any of the arteries 
about the head : the carotid beat naturally. The patient was 
tranquil, felt well, and sat up, which he had not been able to do 
for some time on account of the throbbing in the head pro- 
duced by any motion. He had a good appetite. His food 
was restricted, however, to half a pound of solid farinaceous 
matter per day, and about a pint and a half of liquid. 

6th. " Although all pulsations were at an end, the tumor still 
existed, but in a diminished state. It was thought, that, if left 
to itself, it would in all probability disappear without further 
applications ; but, as the patient lived at a great distance, it 
seemed to be a duty to see that the tumor was certainly and 
perfectly eradicated before he went home to Nova Scotia. The 
best mode of accomplishing this was by the application of 
caustic, which was resorted to without much danger of hemor- 
rhage, the great vessels being cut off. The use of caustic was 
therefore commenced by the application of caustic potash, in a 
solid form, to the wound left by the separation of one of the 
needles. This wound was about one inch long and two lines 
wide. A little blood followed the application, which might 
have arisen from the pressure of the caustic ; and therefore a 
portion of the same substance, in amount eight grains, was ap- 
plied in powder. 

16th. "The caustic had been applied three or four times. 



456 ARTERIES AND VEINS. 

Twice a slight hemorrhage had occurred, requiring an intermis- 
sion in its use. A pulsatory movement having re-appeared in 
the relics of the tumor, the application of ice two or three times 
a day was directed, to be continued as long as the patient could 
bear it. To-day the caustic was re-applied to the ulcerated 
surface, which was about an inch long and half an inch wide. 
The tumor had sensibly diminished in size." 

It will be unnecessary to proceed with all the subsequent 
details of this case. It is sufficient to state, that the different 
portions of the diseased mass which remained were successively 
attacked with caustic potash, and with the occasional application 
of croton oil. Any small arteries which were discovered run- 
nino: into the tumor were treated, as in the commencement of 
the case, by the needles. 

On 5th April an operation was performed to excise a portion 
of the erectile tissue, which existed at the upper part of the 
wound, when a large vessel was opened and tied. 

May 20th. After the wound from the incision and caustic 
was nearly healed, a fulness was perceived at its lower angle, 
immediately above the supra-orbitar foramen. A triangular 
piece of the suspicious part was therefore cut out, and the supra- 
orbitar artery tied. The whole wound, after this last operation, 
was nearly the size of a silver dollar. Strips of adhesive plaster 
were applied to approximate its edges. The wound came to- 
gether with great rapidity. In a fortnight after the last incision, 
it was healed with a lunated cicatrix, and the parts appeared 
perfectly sound. The patient was in excellent health; and, 
May 20th, was discharged to return home. 

Remarhs. — In considering this case, the first circumstance 
which presents itself is its protracted and complicated treat- 
ment. The necessity of this arose from the obstinate character 
of the affection. The first operation was insufficient, and ad- 
ditional interference was required under the various appearances 
which occurred. Four different measures were successively 
adopted. 

1 . The large vessels were interrupted by needles passed under 
the arteries, and compression made on them by a thread in the 
form of a figure of 8. 



VASCULAR OR ERECTILE TUMOR. 457 

2. The ligatures being insufficient to repress the action of 
the smaller vessels, caustic applications were resorted to for the 
purpose of destroying the morbid texture, and in part obliter- 
ating it by the inflammation produced by the action of the caus- 
tic. To this end, a very free application was made of caustic 
potash, and repeated between twenty and thirty times. 

3. Excision of the remains of the vascular texture was per- 
formed, after the arteries supplying it had been so far obliterated 
as to remove the apprehension of hemorrhage. 

4. Compression by adhesive plaster and a bandage had a 
sensible influence in finishing the cure. 

The general treatment gave important aid to the local applica- 
tions. The patient was kept very still, and for the greater part 
of the time in bed, with the head much elevated, ffis food was 
restricted to the smallest quantity, so that he was reduced for 
a time to a state of total prostration of the muscular power. 
During most of the treatment, if a small addition was made to 
his food, its effect was generally seen in the production of 
arterial vibrations and the recurrence of headache. Abstrac- 
tion of blood and the use of purgatives were resorted to when 
necessary. 

It is worthy of remark, that, while erysipelas prevailed all 
around this patient, he was never affected by it in the slightest 
degree during exposure of at least three months. 

In conclusion, it may be said that this affection could only 
have been destroyed by a resolute and active perseverance in 
the various remedies, continued through all the turnings of the 
disease. 

Case CCLXIII. — Remarhahle Case of Aneurism by 
Anastomosis. Operation. Cure. — A boy, 16 years old, 
partially froze the lobe of his left ear in 1818. This remained 
larger than the lobe of the right ear ; and, in fact, slowly in- 
creased in size, finally forming a distinct tumor, red on its sur- 
face, and having a powerful pulsation. In 1852 it was found 
necessary to undertake some means to arrest its growth. For 
this purpose, compression between two plates of metal was 
advised and practised by his surgeon. Although this was done 

58 



458 ARTERIES AND VEINS. 

in the most careful and scientific way, yet the suffering became 
so severe, that, after having persevered with it for a fortnight, it 
wsis found necessary to abandon its further application. 

When the patient applied to me, it was with the full deter- 
mination of having any operation done that might be thought 
expedient. The tumor had arrived at that condition wherein 
it was evident, that, if an operation should not be successful in 
removing it completely, it must soon pass beyond the reach of 
surgery, spreading over the ear and taking possession of the 
face, as in the case cited by Dupuytren in his '^ Legons Orales," 
which resisted numerous and formidable operations, performed 
by some of the most distinguished surgeons in Paris. 

The appearance of the tumor at this time was as follows : 
The lobe of the left ear was occupied by a globular tumor the 
size of a hen's egg. The surface was red, and covered by large 
veins running over it in all directions : the redness and swelling 
belonging to the tumor extended above, into the concha of the 
ear, and ran up for a short distance on its back part. In front, 
it slightly encroached on the cheek. On taking it in the hand, 
it had a powerful pulsating motion ; not that alone presented by 
the common erectile tumor, but, added to this, what might be 
expected in an aneurism of a large artery, the carotid or sub- 
clavian for instance. By manipulation, vessels of considerable 
size could be perceived running into it from the ear and face. 

At first, I was at a loss how to attack the disease, the danger 
of hemorrhage appearing to be great from any cutting operation ; 
and, if ligatures were used, the same danger was to be appre- 
hended on the separation of the threads. A combination of the 
two was finally resorted to. 

The patient being etherized with chloric ether, the tumor was 
dragged upon, so as to stretch the integuments as much as pos- 
sible. A pair of screw forceps, similar to an enterotome, was 
now made to embrace the whole base of the tumor, about three 
inches in length, that is to say, the whole enlarged lobe of the 
ear, with a portion of the cartilage. This was tightly screwed 
up, so as completely to interrupt the course of the blood into 
it. A needle, threaded with a strong double ligature, was next 
passed behind the forceps, and the needle cut off, leaving the two 



VASCULAR OR ERECTILE TUMOR. 459 

threads. The tumor, now apparently effectually controlled, was 
cut away close to the forceps. It was, however, at once found, 
that, on the tension of the parts bemg relieved, that portion of it 
towards the cheek had escaped from the grasp of the forceps, and 
an artery was exposed nearly as large as the external carotid. 
This was seized by an assistant with toothed forceps, and a 
ligature applied to it. The grasp of the forceps being now 
slowly relaxed, it was observed that the whole cut surface was dis- 
posed to bleed. Some large vessels bled violently, and were tied. 
To stop the bleeding from the other parts, it was finally found 
necessary to apply the ligature en masse, which was done by 
means of two double ligatures. In the subsequent manage- 
ment of the case, all means were used to prevent too high a 
degree of inflammatory action about the ligatures. The patient 
was very carefully watched, kept quiet, a low diet enjoined, and 
a compress, constantly wet with cold water, applied. Once or 
twice, blood started by the side of the ligatures, but was re- 
strained by refrigerant applications. At the end of fourteen 
days, the ligatures separated, leaving an exuberant granulating 
surface, upon which the nitrate of silver was freely used. On 
the twenty -third day, the wound was almost entirely healed, 
and the neighboring parts were in a perfectly healthy state ; the 
effect of the inflammatory action having destroyed the enlarged 
capillary vessels which had extended into the concha of the ear, 
and invaded the integument on its posterior part. 

In order to have extirpated all appearance of erectile tissue 
at the first operation, by the knife, it would have been necessary 
to sacrifice nearly half of the ear, and to leave the patient with 
a great deformity. In order to avoid this, I removed the tumor, 
trusting to the effect of inflammation to destroy the erectile 
tissue which remained. 

The appearance of the tumor after removal was quite inter- 
esting. The main portion of it was composed of a spongy 
tissue, which enclosed an aneurismal cavity, apparently the ex- 
pansion of the largest of the vessels described above, which 
were tied when the tumor was removed. From this cavity, 
branches extended in all directions, which finally could be traced 
into the cellular tissue covering the periphery of the mass. 



460 ARTERIES AND VEINS. 

Case CCLXIY. — JSTcevus over the Knee-joint. — A young 
man entered the Hospital in June, 1852, with a nasvus on the 
knee. The nsevus was of a black color, situated over the in- 
ner part of the knee-joint, below the patella. Until within two 
years, the tumor had been about the size of a dollar ; but, since 
then, a supplementary tumor had appeared underneath the origi- 
nal one, not soft, as is usually seen in these cases, but quite 
hard, and extending for some distance into the adjacent cellular 
membrane, and apparently attaching itself to the synovial cap- 
sule. The whole tumor had become extremely sensitive, so that 
even the contact of the clothes caused much suiFering ; and pre- 
vented him from attending to business. It was impossible to 
make any satisfactory examination, the patient dreaded so much 
the slightest manipulations. He was dieted, and kept in the 
horizontal position for a few days ; an evaporating wash being 
externally applied. This had the effect of relieving the tender- 
ness in a slight degree. The whole tumor was now congealed 
by means of a freezing mixture of pounded ice and salt, accord- 
ing to Mr. Arnott's process, which I had just commenced to 
experiment with. The hard basal tumor was then very freely 
cut up by a subcutaneous section. The operation was entirely 
painless, and no unpleasant symptoms ensued. The vicinity 
of the knee-joint of course precluded any operation for the ex- 
cision of the tumor. The above subcutaneous section was, 
therefore, once or twice repeated ; and resulted in the absorption 
of a large part of the tumor, and diminished the sensibility, so 
that it could be handled without suiFering. He left the Hospital 
at his own request ; otherwise, by a repetition of the above 
means, the complete destruction of the tumor would have been 
effected. 

In another case, I removed a similar nsevus, in an ulcerated 
state, situated on the upper part of the calf of the leg. The 
patient was twenty-six years of age. Two years before, the 
tumor had been injured, after which there was much hemorrhage. 
In spite of treatment, it had remained in an ulcerated state. The 
skin around it was much inflamed, and at times very painful. It 
was removed by two elliptical incisions, without much hemor- 
rhage. 



VASCULAR OR ERECTILE TL^IOR. 461 

Case CCLXY. — Unusual Case of Varicose Aneurism of 
Palm of Hand and Arm. Amputation. Recovery. — A 
girl, 19 years of age, of a delicate constitution, received an in- 
jury, when two years old, in the palm of her hand, from a 
stone ; and, very shortly afterward, a small pulsating tumor ap- 
peared there. Twelve years afterward, she entered the Hospital. 
At that time, a large tumor occupied the whole hand, held as it 
were, in the palm. It was firm at some points, soft and pul- 
sating at others ; and seemed to have made its way backward, 
so as to give the idea of all the bones of the hand having been 
flattened, and forming a shell to it. On compressing the tumor, 
it had a powerful aneurismal thrill ; and, in some parts of it, 
the blood seemed to be contained in large aneurismal sacs ; at 
others, arteries of the size of the carotid could be detected. Am- 
putation was advised as the only resource, but declined. A cast 
was made of the arm and hand at the time. 

In addition to the tumor of the palm of the hand, there was 
also a supplementary tumor, quite firm to the touch, reaching up 
the whole fore-arm under the muscles, without pulsation. 

In the spring of 1857, she came under my care again, the 
tumor having more than doubled in size, and the swelling on 
the fore-arm increased in a corresponding manner. At this 
time, a distinct aneurismal thrill attended the pulsation of the 
brachial artery ; and the surrounding veins were in a highly 
varicose state. On auscultation, the tumor of the hand gave a 
sound like the noise of the machinery of a factory. The arm 
was quite unwieldy, and at times very painful ; and the 
disease was rapidly increasing. The surgeons of the Hospital, 
in consultation, decided that amputation was the only means of 
relieving the patient, but considered that there was a possibility 
of meeting with erectile tissue in the arm. She was quite timid, 
and unwilling to encounter any more than the ordinary danger 
from an amputation. She therefore returned home; but, 
subsequently, the pain being so severe, and the tumor making 
advances, by the advice of her physician. Dr. Jones, she came 
to town, and submitted to the operation. In making the com- 
pression, it was deemed necessary to place a tourniquet quite 
high upon the arm, and screw it up so as to forcibly compress 



462 ARTEEIES AND VEINS. 

all the tissues. Nearly twenty vessels, both arteries and veins, 
required ligature, as it was soon found that the veins carried 
arterial blood, and were disposed to bleed. The quantity of 
blood lost in the operation was small, on account of the very 
effectual way in which the compression was applied. 

On the day after the operation, there was a great re-action ; 
and this was so violent on the following day, that it was found 
necessary to take blood from her, which was done with relief. 
The whole stump, however, shortly became of a fiery red color ; 
and a diffuse painful swelhng appeared in the neck, above the 
clavicle. In a week or ten days, this subsided, but one morning 
it was observed that the breast had suddenly become puffed up ; 
and, a day or two after, a great quantity of pus was discharged 
through an incision at this point. 

After a very long convalescence, she went home nearly well. 
During the whole of the after-treatment, there was no hemor- 
rhage from the stump, and no evidence of any erectile tissue 
remaining. 

The arm was very beautifully injected by Dr. H. J. Bigelow, 
and a careful dissection made by Dr. R. M. Hodges. The wax 
injection was thrown into the veins, and returned by the brachial 
artery. The veins of the arm and hand were greatly dilated, 
and formed a beautiful basket-work around the bone : in the 
palm of the hand, they communicated freely with the arteries, 
which were dilated so as to form what might be called large 
sinuses. The solid part of the round tumor in the hand and 
fore-arm was formed of condensed and infiltrated cellular tissue. 

The specimen, together with the cast, was presented by me 
to the Warren Museum. 

I saw her a year afterwards, quite well, and wearing an arti- 
ficial arm. 

Case CCLXVI. — Venous Erectile Tumor of Mouth, 
Lip, and Tongue. — A young woman, 19 years old, entered 
the Hospital, on the fourth day of April, 1864, for a con- 
genital venous tumor, occupying the left side of the under lip, 
which hung down like a bag out of the mouth. The whole of 
the interior of the left cheek was pervaded by the tumor, as also 



VASCULAR OR ERECTILE TUMOR. 463 

half of the left side of the tons^ue. There were traces of it on 
the velum palati. On the outside of the face, a bundle of veins 
could be seen running from the angle of the mouth, and a round 
mass passing up towards the ear, as if from the tumor within. 
The left under-jaw was excavated by the pressure of the tumor. 
She had been suffering with choking turns in the night, appar- 
ently from the obstruction caused by the enlarged tongue. 

I decided to attack the disease by the ligature ; and, if found 
necessary, to expose it by an incision made through the integu- 
ment of the cheek, from the angle of the mouth. 

On the 9th of April, the patient being etherized, the mass of 
the tumor of the cheek and lip was seized with hooked forceps, 
and drawn outwards from the mouth. Two needles, armed 
with stout ligatures, were then passed through the base of the 
tumor, at right angles ; and the ligatures, being cut near the 
eye of the needles, were tied together, so as to embrace and 
stran ovulate the whole mass. The tono^ue was then seized with 
forceps, and drawn out of the mouth : a curved needle, armed 
with a stout ligature, was passed from above downwards through, 
in the median line, just behind the tumor, and returned from 
below upwards, half an inch nearer the tip. The ligature was 
divided, and the ends tied so as to include and strangulate 
the posterior portion of the tumor. The anterior portion was 
then strangulated in a similar manner. The bleeding was very 
slight. 

The tongue swelled so as to fill the entire mouth ; and the 
suffering was great, both from pain and the obstruction to 
breathing and deglutition. On the tenth day, the slough from 
the cheek and lip separated without hemorrhage, leaving an 
ulcerated surface ; and, on the eleventh day, the slough from 
the tongue came away, with the exception of a portion included 
in the posterior ligature, which hung by a small pedicle. 
This pedicle was surrounded by a ligature, and the day after 
separated. She did well, and was discharged on the 6th of 
May. 

On the 17th of September, she returned to the Hospital' for 
the removal of the remaining portion of the naevus. During 
the summer, her health had greatly improved. 



464 ARTERIES AND VEINS. 

She was etherized, and the tumor seized from the inside 
of the mouth, with hooked forceps, drawn forward as far as 
possible, and a double ligature passed through its base. The 
ends were tied both ways, strangulating a large portion. She 
did well, the slough separating on the twelfth day ; and, on 
the 7th of October, she was discharged, apparently entirely 
cured. 



CHAPTER X. 

INJURIES AND DISEASES OF XERVES. 

Injuries of the nerves belong more especially to military sur- 
gery, and have therefore, until very lately, been but little 
studied among us. The information given in the common 
hand-books is also quite meagre, and eminent authorities differ 
widely upon important points both of prognosis and treatment. 

The immediate effects of the division or injury of a large 
nerve are the loss of sensation and of motion, and a diminished 
power of resisting changes of temperature, which would ordina- 
rily cause no inconvenience. Severe pain is also a very com- 
mon symptom, but is not always observed until the lapse of a 
certain time after the receipt of the injury. The loss of sen- 
sation and of motion may be either temporary or permanent, 
as might naturally be expected : but the connection between the 
precise nature of the injury and the subsequent phenomena has 
not often been marked out with so much exactness as could be 
desired. 

The proposal of the plan of treating nervous affections by 
neurotomy involves the whole question of the repair of injured 
and divided nerves ; a subject not very fully discussed in works 
on surgery, and therefore not very familiar to practical sur- 
geons. 

As regards the question of re- union of the two ends of a 
divided nerve, there is no doubt that such a result often occurs. 
A sufficient proof of this fact is seen in the restoration of ner- 
vous action in the trifacial nerve, even after the removal of a 
portion of one of its larger branches for facial neuralgia ; also 
in the occasional reproduction of the nerves in the foot of the 
horse, when divided or partially excised, to conceal or relieve 

59 



466 INJUKIES AND DISEASES OF NERVES. 

certain forms of lameness. The same fact is also proved physio- 
logically by the experiments of Cruikshank and Haighton upon 
the vagus of dogs ; and anatomically by Meyer, Swan, Tiede- 
mann, and others, who have actually traced the new nervous 
filaments in the cicatricial tissue, uniting the cut ends, and filling 
the void caused by the excision of a portion of several lines (and 
in one case nearly an inch) in length. Clinical observations 
bearing upon the same point are recorded by various authors. 
Mr. Syme, in his "Treatise on the Excision of Diseased Joints" 
(Case VIII., page 88), gives a remarkable case, in which the 
ulnar nerve was wholly divided at the elbow, in the operation 
of excision of that joint, and in which the functions of the nerve 
were perfectly restored in the course of a few weeks. A sub- 
sequent dissection of the arm, less than a year after the opera- 
tion, revealed the fact that perfect union of the cut ends of the 
nerve had taken place, and that the nervous filaments could be 
traced from both ends into the intermediate new tissue, and 
apparently also from one end to the other. In a similar case, 
reported by M. Roux, a portion of the ulnar nerve was actually 
cut away : but, in the course of a year, sensation had entirely 
returned ; and when the patient was examined, fourteen years 
after the operation, the sensation was as perfect as in the other 
arm. Mr. Paget also, in his valuable "Lectures on Surgical 
Pathology," gives cases of the return of the functions of the 
nerves after their division. 

In view of these facts, it is important to inquire into the pro- 
priety of dividing the nerve as a remedy for traumatic neuralgia. 
In answer to this question, it may be stated, that, if the nerve is 
simply divided, sensation will probably return before the tissues 
implicated in the original injury have had time to recover their 
normal condition ; and that therefore the operation will aflPord 
only very transient relief, and may have to be repeated several 
times. If, on the other hand, a portion of the nerve is excised, 
the restoration of the nervous function will be very much longer 
in taking place ; but there will also be great danger that the 
repair will be incomplete, or even that it may fail altogether, 
and thus entail permanent loss both of sensation and of motion. 
The deliberate removal of a lonoj section of the nerve, with a 



INJURIES AND DISEASES OF NERVES. 467 

view to the permanent abolition of its functions, can be but very 
rarely indicated, and then only as a last resort, as the pos- 
sible alternative of amputation. 

The rational treatment of these neuralgic affections seems to 
me to be based on the fact, that their natural tendency is to 
recovery, if only we can keep the patient comfortable, and thus 
induce him to wait for this tardy relief. This can only be 
effected by division of the nerve, or by the use, either local or 
general, of narcotics. The protracted use of opium internally, 
in sufficient quantity to relieve the pain, will almost inevitably 
exert a most pernicious influence on the health, while mere local 
applications to the skin seem to have very little effect. The 
great benefit which has been derived from the use of hypodermic 
injections of morphia for ordinary neuralgia naturally suggested 
the propriety of trying them in this affection ; and the success 
which has attended the experiment has been most gratifying. 

The followino; cases of severe traumatic neuralo-ia, which have 
occurred in my practice, serve to throw light upon certain 
points in the pathology and treatment of this painful affection. 
In all these cases, the injury seems to have been to the tissues 
surrounding a nervous trunk, rather than to the nerve itself; 
and the immediate cause of the painful affection which followed 
would seem to depend upon the effusion of inflammatory pro- 
ducts within the dense fibrous neurilemma, thus entangling the 
nerve in a mass of cicatricial tissue, perhaps also compressing 
its fibres. The highly favorable result, in the first case, may be 
readily explained by the well-known law of development of new 
reparative material, by which it becomes gradually assimilated 
to the proper tissue of the part in which it is deposited. The 
dissection made in the course of the operation showed that the 
nerve was then firmly glued to the surrounding tissues ; and its 
release from these connections was followed by perfect relief of 
the pain, which, however, returned in a diminished degree, as 
soon as the process of cicatrization had again commenced. The 
pain was then controlled during six months by the daily use of 
hypodermic injections of morphia ; and, at the end of this some- 
what protracted treatment, the neuralgic affection was found to 
have disappeared, and the nerve had so far recovered its normal 



468 INJURIES AND DISEASES OF NERVES. 

condition as to conduct ordinary sensations in a very satisfactory 
manner. The second and third cases are equally important, as 
showing the powerful effect of the narcotic injection ; in the one 
case in relieving the pain, and in the other actually curing it. 

Case CCLXVII. — Severe Neiiralgic Affection following 
a Gunshot Injury of the Median Nerve. Subcutaneous Injec- 
tion of Morjphia. Operation. Injection continued for nine 
months. Recovery. — In the second battle of Bull Eun, Lieu- 
tenant A. was struck by a ball, on the outside of the middle of the 
arm. The ball passed obliquely through, traversing the biceps 
muscle, and coming out on the inside of the arm. For two or 
three days, he was exposed to the weather, lying under the piazza 
of a house, having but little food, and with his hand constantly 
wet with the rain which was falling. The hand was benumbed ; 
but he suffered somewhat with a sensation of heat in it, which 
was partially relieved by keeping it exposed to the wet. There 
was no pain in the wound itself. Shortly after, he was removed 
to Washington, where he first experienced very severe pain in 
the whole hand, but more particularly in the part of it supplied 
by the median nerve. I saw him about a fortnight after the 
receipt of the injury. He was then in constant and severe pain 
in the hand ; so much so, as to require to be kept more or less 
under the influence of morphia, which he was taking to the 
amount of a grain a day. On examining the point at which the 
wound was received, a puckered eschar was seen, with an indu- 
ration extending deeply into the belly of the biceps muscle, to 
which the skin was adherent. The situation occupied by the 
vessels and nerves, on the inside of the biceps, was also envel- 
oped in a mass of indurated tissue. The first idea suggested by 
this state of things was to cut down upon the nerve, and divide 
it. It seemed, however, possible, by the gradual change going 
on in the tissues, that a healthy action might ultimately be set 
up ; and, at the same time, the indurated tissue surrounding and 
compressing the nerve might be absorbed, finally relieving the 
nerve from pressure. The question was, whether the sufferings 
of the patient could be sufficiently mitigated, by artificial means, 
to allow of the adoption of a temporizing course. He was ad- 



TRAUMATIC NEURALGIA. 469 

vised to place the limb perfectly at rest, wear it inside his clothes, 
next the body, and to have a sleeve made of sheet India-rubber 
to envelop the lower part of the arm, which covering was to be 
removed from time to time, the arm exposed to the air, and 
washed with soap and water : he was directed to discontinue the 
use of the rubber sleeve if much irritation was set up in the skin, 
and to envelop the arm in flannel instead, which he had pre- 
viously found necessary, owing to the great reduction of tempera- 
ture. He went home, and followed this plan for three or four 
weeks. At the end of that period, he came to me again, with 
the desire of having the nerve divided ; as his sufferings had 
become so intolerable, in spite of the use of opiates, as entirely 
to deprive him of rest. Before resorting to an operation on the 
nerve, I determined to try the effect of subcutaneous injections 
of morphia. Half a grain of sulphate of morphia, in solution, 
was injected deep under the skin of the fore-arm twice a day. 
He was at once placed in a state of comparative ease ; and the 
evening injection gave him a good night's rest, such as he had 
not enjoyed for many weeks. This plan was followed up for a 
month, with equally good effects : his digestion was not in the 
least affected by the use of the morphia, and he gained consid- 
erably in flesh. If, however, the dose Avas omitted, the pain 
became as severe as ever. It was therefore decided to perform an 
operation. An incision of three inches in length was made over 
the inner edge of the biceps, and the integument dissected on 
both sides separating the cicatrices, caused by the entrance and 
exit of the ball from the subjacent tissues. The indurated mass 
which surrounded the vessels and nerves was now cut into ; and 
the median nerve being discovered, where it entered, was gradu- 
ally laid bare and dissected out, so that it lay perfectly loose in 
the wound for an inch and a half or two inches of its lenoth. 
It was thought best not to divide the nerve, but to await the 
result of the healins: of the wound. The edoes of the wound 
were loosely approximated, and water-dressings applied. For 
some days the pain was entirely relieved, although, from the 
effect of the habitual use of morphia, a small dose was required 
to promote sleep. As the wound began to heal, however, the 
pain recurred, but with much less severity than before. Desiring 



470 INJURIES AND DISEASES OF NERVES. 

now to return home, one of his family was instructed in the use 
of the subcutaneous injection of morphia. About two months 
afterwards he called on me, and again (March 20, 1863) four 
months after the operation. He was then in a state of perfect 
health, and had gained much flesh, but complained still of 
neuralgic pain in the hand, requiring the employment of the nar- 
cotic injection ; whether from habit or not seemed to be a ques- 
tion. The arm, hand, and fingers had begun to acquire some 
motion. In regard to the local effect of the injections, it may be 
said, that, although they had been used twice a day for five 
months, he had never suflPered from any irritation at the point 
of puncture, except in one instance ; in the case of a freshly pre- 
pared solution of sulphate of morphia, the use of which was fol- 
lowed by the production of a large red blotch, whenever it was 
injected. On substituting a solution of acetate of morphia, no 
farther trouble of this nature was experienced. This accident 
is probably to be explained by the common practice of adding 
free sulphuric acid to promote the solubility of certain specimens 
of sulphate of morphia. The acetate is very soluble in water. 
The patient had had nearly three hundred injections of morphia ; 
and, with the above exception, no traces remained of its pro- 
tracted use. 

Oct. 26, 1863. — I saw this patient, and found that he had 
recovered his health, and enjoyed complete immunity from pain. 
The hypodermic injections were continued until the month of 
July, or about nine months from the receipt of the injury. He 
then, by a great effort, suddenly discontinued them, and had 
not used them since. The neuralgic affection, except during 
extreme changes of the weather, had left him. The fore-arm 
had recovered its natural sensibility : he had the power of com- 
plete flexion of the elbow, and of partial rotation of the fore-arm ; 
while the fingers, which were formerly held in a state of exten- 
sion, could be approximated to the thumb, so as to make the 
hand useful for most of the ordinary purposes of life. This 
motion was continually improving. 

Case CCLXVHI. — Gunshot Wound of the Thigh, impli- 
cating the Sciatic Nerve. — In April, 1864, I had under my 



TRAUMATIC NEURALGIA. 471 

care, in the Hospital, a soldier, who, two months before, was 
shot in the thigh, and taken prisoner. The ball traversed the 
thigh from side to side, and probably injured the sciatic nerve, in 
the immediate neighborhood of which it must have passed. He 
suffered no inconvenience in the site of the wound ; but, shortly 
afterward, a severe neuralgic pain commenced in the sole of the 
foot, accompanied by a sensation of heat and great tenderness of 
the part, and enth^ely incapacitating him for locomotion. Opiates, 
in the usual form, gave him but little relief; and the only allevia- 
tion of his sufferings, while in prison at Kichmond, was obtained 
by keeping the leg constantly plunged in a pail of cold water. 

I ordered the subcutaneous injection of a quarter of a grain 
of morphia daily into the leg, and gradually increased the dose 
to a grain a day. By this treatment, the pain was completely 
held in check, rendering his days and nights comfortable. The 
full effect of each dose was obtained in from five to ten minutes 
after injecting it. The patient left the Hospital very much 
relieved ; and I lost sight of him afterward. 

In tlie course of this case, I experimented as to the effect of 
the injection, when made at a distant part of the body, as com- 
pared with its effect when applied in the immediate vicinity of 
the affected nerve. I found that, when the injection was made 
in the opposite limb to that affected, the relief was as prompt 
and as complete as when made directly over the course of the 
nerve ; and this occurred repeatedly, in every instance in which 
it was tried. This is a point of very considerable importance, 
inasmuch as it is often very inconvenient to make the injection 
in the exact situation of the affected nerve, as has been strongly 
insisted on by several writers upon this subject. 

Case CCLXIX. — Injury of the Ulnar and Musculo- 
Spiral Nerves^ from a Bullet, — Captain C, who had already 
been twice wounded in the thigh and leg, in the battles of Win- 
chester and Fredericksburg, was struck at the battle of Gettys- 
burg by a ball, just over the median nerve of the arm. It 
passed in a spiral direction around the bone, and came out half- 
way down the limb below on the other side. The hand and 
fore-arm were at once partially paralyzed ; and, in a day or two, 



472 INJURIES AND DISEASES OF NERVES. 

very severe neuralgic pains commenced, principally in that part 
of the hand supplied by the ulnar nerve. When I first saw 
him, about a week after the injury, the arm was much swollen ; 
and the wounds, which had still on them the cold water-dress- 
ing, were in an irritable state, and there was no appearance of 
suppuration. The water-dressings were replaced by a large 
warm poultice ; and, on a free suppuration being established, 
the extreme pain in the arm and hand was much relieved. The 
pain, however, still continued to recur at intervals, and the par- 
oxysms coming on at night were very severe. Finally, the hy- 
podermic injection of morphia was tried, and a single dose of 
one-half grain afforded entire relief for the time being ; and, 
in fact, destroyed the habit so that the paroxysms did not recur. 
The hand and arm, however, for a long time afterwards, were 
very uncomfortable, on account of the excessive heat of the 
parts, which was only relieved by the constant use of cold water ; 
and it was not until after several months that the normal sensi- 
bility began to return, and this symptom to disappear. Seen 
again at the end of five months, he was free from neuralgic pain, 
had some use of his hand, and the elbow had become flexible 
after employing forcible extension to overcome the stiffness pro- 
duced partly by inaction, and partly by the contraction of the 
injured muscles. The movement of rotation of the fore-arm 
had not been recovered, although it could be easily made by 
a second person, the nervous power being still deficient. 

The three cases which follow are instances of excessive neu- 
ralgia affectins: the inferior dental nerve, in which all known 
medical means had been resorted to without avail, and where 
life had become insupportable. An entire relief was the result 
in two of the cases, and a partial relief in the other, by trephin- 
ing the inferior maxillary bone near its angle, exposing and 
excising a portion of the nerve as it lay with its vessels in the 
bony canal. 

Case CCLXX. — Facial Neuralgia, Trephining the Low- 
er Jaw, and Removal of a portion of the Inferior Dental Nerve. 
Partial Relief — In October, 1859, a young man, 23 years 



FACIAL NEURALGIA. 473 

of age, entered the Hospital on account of facial neuralgia, of 
two or three years' duration, in the right side of his face. When 
the pain first appeared, it was attributed to carious teeth, which 
were removed, but without relief. The pain was very severe 
and paroxysmal, occurring after speaking or eating. Brisk 
friction gave temporary relief. He was treated by tonics and 
narcotics internally, and by hypodermic injections of morphia. 
The extract of conium, in doses of five grains, seemed to give 
most relief. On Xov. 12th he was discharged, relieved. 

The relief, however, was only temporary. He entered the 
Hospital again, Aug. 20, 1861. Meanwhile he had been oper- 
ated upon, and two nerves divided in the upper jaw. 

His jaw was now trephined by one of the surgeons of the 
Hospital, who removed a portion of the bone half an inch in 
diameter, with the contained portion of the inferior dental nerve. 
He had entire relief for three or four months, at the end of 
which time he experienced occasionally attacks of pain : their 
severity and frequency increased ; and on the 2 2d of April, 
1863, he again entered the Hospital, and came under my care. 
Quinine and Fowler's Solution internally, and subcutaneous in- 
jections of morphia, were tried without effect ; the pain rather 
increasing. He insisted on another operation, which was done 
on the 23d of May : being, of course, under ether. An incision 
one and a half inches long was made parallel to the body of the 
jaw near its lower border, and another one joining this made 
along the edge of the ramus. The flap was dissected up, expos- 
ing the bone. A portion of the ramus near its junction with 
the body of the jaw was denuded of its periosteum. A piece of 
bone half an inch in diameter was now removed by a trephine 
just below the inferior dental foramen. Great care was neces- 
sary while trephining, in order not to fracture the jaw, so much 
of its substance having been excised at the previous operation. 
After removing the bone and exposing the nerve, half an inch 
of it was taken away. Temporary relief followed the operation. 
The disease, however, afterwards recurred, but in a mitigated 
form ; and his subsequent history is not known. 

It is important, where the bone is excised on the ramus of 
the jaw, not to go above the internal aperture, where the dental 

60 



474 INJUBIES AND DISEASES OF NERVES. 

nerve penetrates the jaw. Otherwise, the whole substance of 
the bone will be removed ; and the gustatory nerve, as it passes 
along the inner side of the ramus of the jaw, may be mistaken 
for the inferior dental nerve. 

Case CCLXXI. — Neuralgia, Relief hy Trephining the 
Lower Jaw-bone for the Removal of a portion of the Inferior 
Dental Nerve. — In July, 1847, Dr. J. C. Warren removed 
a portion of the inferior dental nerve by trephining the body 
of the jaw in a lady fifty-nine years old, and thus afforded her 
relief from an excruciating neuralgia of three years' standing. 
She had no recurrence of the pain until a year after ; and then 
the suffering returned, and became so severe as to confine her 
to the bed. She was unable to eat or speak without causing a 
paroxysm of pain. The pain commenced in the lower jaw, 
always at the same spot, and thence extended over the whole 
side of the face. 

A year and a half after the operation, her son, a medical man, 
applied to me, saying that something must be attempted for her 
relief. I suggested an operation for trephining the jaw farther 
back than had been done before, and removing a portion of the 
nerve near where it enters the inferior dental foramen. This 
was readily agreed to. 

An incision beino' made from the sio^moid notch down to the 
edge of the jaw, the parotid gland was raised and turned back. 
The lower portion of the masseter muscle was now dissected up, 
and a section of bone removed by means of the trephine and 
chisel. Half an inch of the now fully exposed nerve was ex- 
cised. The inferior dental artery was unavoidably cut and tied. 

For ^Y^ or six days subsequently, there was a slight discharge 
of saliva from the wound, owing to the interference with the 
parotid ; but it healed favorably, and the operation was attended 
with the most complete relief. I heard from the patient a year 
afterwards, and there had then been no recurrence of the neu- 
ralgia. 

Case CCLXXII. — Facial Neuralgia, Trephining the 
Lower Jaw, and Removal of a portion of the Inferior Dental 



NEURALGIA. 475 

Nerve. — 1858. A lady, aged 40, had suffered for eight years 
from neuralgic attacks in the right side of the lower jaw. At 
times, the pain was excruciating. During this period, every kind 
of treatment that the best-directed skill and judgment could 
dictate was employed, but without avail. All the teeth in both 
jaws had been extracted, but Avith only temporary relief. I was 
called in consultation in 1854, and then advised an operation ; 
but she declined to undergo it. The pain extended from the 
jaw to the upper part of the face ; and her sufferings became so 
great as to confine her to her room, and reduce her strength. 
For the greater part of the six months before the operation, 
she was kept under the influence of morphia. The slightest 
motion near her, or an unexpected draught of air, were suffi- 
cient to excite an attack. Under these circumstances, finding 
that all the means tried had failed^to relieve her, she consented 
to an operation. 

Under ether, the jaw was exposed at the edge of the masseter 
muscle ; and, the latter being raised, the trephine was applied, 
and a circle of bone about half an inch in diameter removed. 
This opened the inferior dental canal. The nerve was now lifted 
on a probe, and as large a portion of it as the aperture would 
admit of excised. It was again divided where it issues from 
the mental foramen. The enlarged and irregular alveolar pro- 
cesses were next cut away wdth the bone forceps. 

She recovered rapidly from the operation ; and, for a year, 
enjoyed entire immunity from the neuralgic attacks. From 
that time to 1867, a period of more than eight years, there were 
occasional paroxysms of facial neuralgia, with considerable gen- 
eral nervous disturbance ; but she had not been confined to her 
room except during these attacks. During the intervals, she had 
been in fair health. 

Case CCLXXIII. — Neuralgia. Excision of the Digital 
Nerve of the Forefinger. — A lady, 35 years of age, in 1843, 
was seized, while pregnant, with a severe pain in the tip of the 
forefinger of the right hand. The only cause to which she could 
attribute it was the too free use of the needle. The pain had 
gradually increased, affecting the arm and shoulder, and finally 



476 INJUEIES AND DISEASES OF NERVES. 

other parts of the body on the same side. Every remedy 
which the experience of distinguished surgeons in the vicinity 
could suggest had been ineffectually tried. Aside from the 
above disease, her health was good, and she was in good con- 
dition. The appearance of the finger was somewhat red, and the 
motions impaired. The slightest examination caused excessive 
suffering. Although informed that the success of an operation 
was doubtful, she consented to its performance, and it was 
done in the following manner : — 

After she was etherized, an incision was made a little in 
front of the inner aspect of the first phalanx of the finger, the 
digital nerve exposed, and about .half an inch of it excised. 
The same operation was repeated on the other side. The end 
of the finger became at once benumbed, and the pain ceased. 
She returned home five days after, free from pain ; and, two 
months later, I heard that she was perfectly well. 

The operation, so far as I have since learned, was successful ; 
but it must be confessed, that, in operations of this kind, the 
relief is very apt to be but temporary. However, a mitigation 
of suflfering, even for a time, renders it worth while to perform 
it ; and I am not aware that any permanent ill effects arise 
from it. 

Case CCLXXIY. — Injury of a Nerve from Puncture with 
a Needle, Treatment without an Operation, Cure. — A lady, 
35 years of age, of delicate organization, was sent to me, for a 
stiffness and loss of use of the thumb of the left hand, owing to 
an injury from the prick of a needle, received about a month 
before. The injury was not attended with much pain at the 
time, but an irritation shortly commenced in it, which extended 
up the arm to the shoulder ; and, without much apparent in- 
flammation of the lymphatics, a swelling took place near the 
axilla, which suppurated. The whole hand became more or less 
stiff and useless. 

When I first saw her, the thumb itself was entirely im- 
movable : any effort made to approximate it to the forefinger 
caused great pain, and the whole appearance led me to suppose 
any attempt at restoring its motions would be likely to result 



TRAIBIATIC NEURALGIA. 477 

in failure. I recommended to her a tonic course, and free ex- 
ercise out of doors ; to bathe the whole arm witli warm salt and 
water twice a day, and the hand and tliumb with an anodyne 
embrocation, alternated with frictions of sweet oil. The thumb 
itself was kept constantly warm and moist by the use of a loose 
cot of oiled silk. 

Under this treatment, more or less varied from time to time, 
the patient very gradually recovered a little motion in the thumb. 
The improvement, however, was very slow, and scarcely per- 
ceptible from week to week ; and it was many months before she 
could allow the passive motion even of the parts. By perseve- 
rance in this course for nearly a year, she ultimately recovered ; 
and I saw her some years afterwards, when she consulted me on 
the case of one of her children, without any return of it. 

This treatment of warmth and moisture, with entire rest of 
the limb, combined with an invigorating course for the general 
health, I have found effectual in a number of cases. 

Case CCLXXY. — Neuralgia of the Forefinger from an 
Injury. Operation. — In December, 1861, a young man, 19 
years old, applied to me to amputate the forefinger of his right 
hand, on account of its excessively sensitive condition, produced 
by an injury which he had received nine years before. The fin- 
ger had been caught in a fulling mill, the soft parts lacerated, 
and the bones crushed. Under the skilful care of his physician, 
the finger was saved, with but a partial stiffness of the phalangeal 
articulations. The skin, however, was left in a state of exalted 
sensibility, so that he could not bear the slightest contact of it 
with another body ; making it almost impossible for him to dress 
himself, or to pursue his ordinary avocations. When he con- 
sulted me, he had undergone almost every conceivable kind of 
treatment, and was desirous of relief from further sufferino-, 
even at the expense of amputation. I proposed to him, before 
submitting to its removal, to make trial of a course of treat- 
ment which I had found successful in a number of similar cases 
arising from traumatic causes. This was to keep the whole 
limb in a state of perfect rest, confined by a sling beneath the 
clothes, so that the act of dressing should involve no muscular 



478 INJURIES AND DISEASES OF NERVES. 

exertion ; secondly, to keep the whole capillary circulation of 
the arm stimulated by wearing a sleeve of oiled silk, extending 
from the shoulder over the hand, and closed at the end so as 
entirely to exclude the atmospheric air ; thirdly, to be put 
under a full course of the iodide of potassium. He agreed to 
adopt this plan, and report to me in a fortnight; but did not 
make his appearance again until the fifth of March, after an 
interval of two months and a half, when he would not admit 
that he had experienced much benefit. I now proposed to him 
to have the finger girdled by subcutaneous incisions, so as to 
destroy the whole nervous supply to the finger, sparing, of 
course, the extensor and flexor tendons. 

The operation was performed, and resulted in the entire re- 
lief of the pain. Two years after, I heard from the patient : the 
finger was then of good color, and free from pain ; but there 
was entire loss of power over it, and it remained constantly 
cold. 



CHAPTER XL 

TUMORS. 

1^ the present chapter, it is proposed to give instances of innocent 
and malignant tumors, with the operations for their removal. 
The subject of their pathology will not be entered upon. Since 
the w^ork of Dr. John C. Warren on Tumors, published thirty 
years since, the subject has been ably elaborated both in this 
country and Europe. 

The diagnosis and treatment of tumors, and the operations 
performed for their removal, constitute one of the most impor- 
tant departments of surgery. In many operations, such as the 
ligature of arteries, amputations of limbs, operations on the 
bladder, &c., certain exact rules can be laid down for the guid- 
ance of the surgeon ; but with tumors the case is diiFerent. 
They are situated at times merely in the integument ; again they 
are found deeply imbedded in the tissues, and not infrequently 
involve important arteries, veins, and nerves. For their safe 
removal, a thorough anatomical knowledge and presence of mind 
on the part of the surgeon are absolutely requisite. The patient 
to be operated on should be well etherized, and in a recumbent 
position as a general rule : the incisions in the skin should be 
free, as they facilitate the subsequent stages of the dissection. 
The envelopes of the tumor are to be cut dow^n upon boldly, 
without too much preliminary dissection. In the removal of 
tumors from deep and dangerous situations, it is well to secure 
the vessels as they are divided. 

Great care is necessary in the operation for recurrent tumors 
situated deeply in the neck, from the adhesion, and at times in- 
corporation with them, of important vessels and nerves. The 
question of the propriety of operating upon leucocyth^mic glan- 



480 TUMORS. 

dular tumors occurring in the neck has recently arisen. The 
true nature of these growths was first described in 1845, by 
Bennett and Virchow. They are characterized by an increase of 
the number of white corpuscles in the blood, and are frequently 
co-existent with an enlargement of the spleen and lymphatic 
glands. They are usually seen by the surgeon as a mass of soft, 
movable tumors in the neck, and are a source of inconvenience 
in respiration ; but do not, as a rule, give much pain. In those 
that I have seen operated upon, some have recovered, others 
have died ; the disease in the latter being found to have exten- 
sively invaded the glands of the chest. According to the present 
state of our knowledge, when other treatment fails, the tumors 
may be removed in the hope of relief or palliation, just as we 
operate upon scrofulous glands or malignant growths. The 
subject, however, remains undecided. 

The question of the removal of malignant tumors by surgical 
operation has been a subject of discussion from the time of the 
Father of medicine. It was the opinion of Hippocrates that the 
disease had much better be left to itself; and that the patient 
died sooner when the attempt was made to remove it, than when 
it was allowed to pursue its natural course. The same views, 
substantially, have been held, until within a few years, in Eng- 
land and the United States. 

In a report made to the American Medical Association in 
1852, supported by cases which had occurred in my own prac- 
tice, I felt justified in drawing the following conclusions : first, 
That, in a certain number of cases, malignant tumors, once re- 
moved, do not return ; secondly. That, in certain other cases, 
the patient, after an immunity for a longer or shorter period, 
has a return of the disease, requiring a second operation, which 
sometimes proves successftd ; thirdly, That, although in a great 
proportion of cases of extirpation, the disease returns, either in 
the neighborhood of the wound or in some internal organ, yet, 
even under these circumstances, it generally re-appears in a less 
loathsome form, and is attended with much less suffering, than 
if the original local disease had been allowed to proceed to a 
fatal termination; fourthly, In consequence of the immunity 
from pain afforded by the use of anaesthetic agents, one of the 



TUMORS. 481 

most serious of the old objections to extirpation no longer 
exists. 

After an experience of fourteen years since this report was 
made, I feel even more fully convinced of the propriety of re- 
moving malignant tumors, — particularly of the breast, — except 
in cases of marked impairment of the health from the disease, 
or when there is evidence of decided constitutional infection ; 
and this opinion would be justified, even if we admit that the 
disease is never really destroyed by surgical removal. I am 
fully confident, however, that, in a certain number of Instances, 
the disease is radically extirpated by the operation. There are 
still living, and in good health, several j)atients upon whom I 
operated for undoubted malignant disease ten or fifteen years 
since. I have also a patient, now in a state of perfect health, 
in whom the disease occurred five separate times within two 
years, and was as often removed ; the last time, more than six 
years ago. In another case, operated on in 1859, In which a 
large scirrhous tumor of the breast was rapidly approaching the 
surface, the whole disease was removed, and the patient recov- 
ered her health. At the end of eighteen months, a tumor ap- 
peared In the axilla, which, after attaining the size of an apple, 
was enucleated from amono^ the orreat vessels and nerves. At 
the end of a year, a hard tumor, imparting almost a bony sensa- 
tion, appeared near the spinous process of one of the dorsal 
vertebrae : this was also removed ; and the patient finally died, 
with cerebral symptoms, four years after the first operation. 
During all this period, she was cheerful ; and most of the time 
was able to take long journeys, and to enjoy the society of her 
friends : the question of cancer was never mentioned between 
herself and her surgeon. This is an extreme case ; and perhaps 
some might question the choice between a large ulcerated, 
sloughing cancer, and the alleviation, both mental and physical, 
afforded by repeated operations. 

In regard to the propriety of operating for the removal of 
epithelial disease, of course there can be no question : cases 
of cancer of the lip and of the fiice being of constant occur- 
rence, in which there has been no return of the disease after 
its removal. 

61 



482 TUMORS. 

The cancers of the breast, which, according to my experience, 
have been the most painful, rapid, and least amenable to surgical 
treatment, are those developed during lactation ; and they often 
occasion great embarrassment in diagnosis. The breast swells, 
becomes indurated, and presents the appearance of an obstruc- 
tion in the lactiferous ducts : in spite of remedies, however, the 
hardness increases ; the skin becomes rough and brawny, and 
the whole organ solidly fixed to the ribs ; cancerous tubercles 
appear in the vicinity : and the patient often dies with either 
cerebral or spinal symptoms. The wound made by the removal 
of a tumor of this kind is very large, usually involving the 
loss of the whole integument over it. I have once or twice 
operated for this disease, — at the earnest solicitation of the 
l)atient, on account of intense pain, — dressing the wound after- 
wards with fiour, which avoids the necessity of subsequent ex- 
posure to the air during the dressings. 

It is not unworthy of notice, that in removing large tumors 
on the left side of the chest, over the region of the heart, great 
depression of the vascular system, attended with symptoms of 
collapse, is often seen to occur from the exposure of the large 
surface to the air ; the symptoms disappearing as soon as the 
wound is covered. I have therefore made it a rule, while the 
vessels are being secured, to expose only as small a portion of 
the wound as is absolutely necessary. 

The question of the destruction of malignant disease by means 
of caustics is one of much interest, the practice having found 
both advocates and opponents among men most distinguished in 
the surgical art. Great mischief is done in this way by char- 
latans, who make use of caustics for the destruction of all kinds 
of tumors, innocent as well as malignant, whose removal they 
would never dare to attempt with the knife. The chief objec- 
tion to the use of caustics, in all but a few exceptional cases, is 
the extensive destruction of integument, which often renders the 
cure very slow and imperfect. In cases of small or superficial 
malignant tumors, especially of the epithelial variety, caustics 
sometimes answer a good purpose ; but if the tumor is large, or 
deeply seated, the process is both tedious and disgusting. If 
ineflficiently employed, they appear to do great harm by stimulat- 
ing the growth to increased action. 



FUNGOID TUMOR OF FOREHEAD. 483 

The most efficient caustic, perhaps, is the chloride of zinc, 
made into a paste with flour, and planted well down into incisions 
made with tlie knife. Another, advocated by Velpeau, and 
I believe also by Mr. Syme, consists of strong sulphuric acid, 
mixed with charcoal or some vegetable powder. The treatment 
of cancer with the hypodermic injection of dilute acetic acid, 
introduced by Dr. Broadbent, has lately been attracting much 
attention in England ; and, from the evidence given in its 
favor, certainly deserves a fair trial. Small cancerous tuber- 
cles probably offer the best subjects for it. I have seen the 
effect of it only in one case ; a large, solid, fixed tumor of a 
hopeless character, situated just behind the ear, in a male patient 
of about 40 years of age. In this case, the surface of the 
tumor was first laid bare by a free incision, and the acid injected 
into its substance. Now, at the end of two weeks, there is a 
discharge of thick, creamy pus from the exposed part of the 
tumor; and the bulk of it — which was of a scirrhous hardness 
— has now a sort of spongy softness. The case was operated 
upon, and is under the care of one of my colleagues at the 
Hospital. 

In connection with the etiology of cancer, I would say, that I 
have had several well-marked cases, in which the diathesis was 
evidently awakened by a blow ; the patient subsequently dying 
of malio'nant constitutional disease. 

o 

The following unusual case of fungoid tumor, apparently ori- 
ginating in the dura mater, operated on by Dr. J. C. Warren, 
is introduced here, with the colored delineation of it which forms 
the frontispiece, on account of the remarkable features connected 
with it. The patient applied to me for advice once or twice, 
some years after the operation, and I have been able to follow 
the history of the case since. 

Case CCLXXYI. — Fungoid Tumor of the Forehead. 
(See Frontispiece.) — "In the year 1846, a young lady applied 
to me on account of a tumor on the forehead, near the right 
temple, having the aspect of a periosteal tumor. 

" I advised an incision across it, to ascertain its character, and, 
if found to be susceptible of an operation, that it should be 



484 TUMORS. 

removed. This was not done ; and in October, 1847, she again 
presented herself. The tumor was then of two years' growth. 
It was of large size, approaching that of a lemon ; its surface 
was ulcerated, fungoid, and bleeding. There was no pain in it, 
nor any cerebral affection. Under these circumstances, I advised 
that the tumor should be cut out, if possible, and the bleeding- 
surface cauterized. 

"Oct. 27th. A projecting fungus, of two or three inches' 
height and width, was first removed, and sufficient evidence 
obtained of its being of a fungoid character, if any were want- 
ing. The surrounding skin, temporal fascia, and muscle, were 
divided on each side of the tumor, which, while it extended 
a space three inches in diameter under the skin, was found to 
have a contracted cervix of not more than an inch and a half in 
diameter. Around this cervix was found the edge of a perfo- 
rated bone. An instrument, passed along this edge, entered the 
cavity of the cranium. The tumor being cut down close to the 
bone, the actual cautery was applied by a succession of heated 
irons. There was a copious hemorrhage ; but one or two liga- 
tures only were applied. The patient, being under the influence 
of ether, suffered nothing. 

" Nov. 6th. The patient had no bad symptoms after the opera- 
tion. At this time she was sitting up, quite comfortable, and 
experienced no pain in the head. The wound, however, had an 
unfavorable aspect ; its edges were nearly an inch tliick, and 
had a puffy or swollen appearance. The fungus had again shot 
up half an inch, and required the daily use of caustic potash. 
From this time to the 15th of December, the caustic was fre- 
quently applied, but was subsequently omitted ; and, on the 17th 
of January, there was a small shell of exposed bone to be found 
at the bottom of the cavity, which Avas about two lines in diam- 
eter, with healthy granulations. On the 31st of August, it is 
recorded that the wound closed soon after leaving the Hospital ; 
the shell of bone previously described still remaining in situ, 
none ever having come away. Health good." 

I was consulted by this patient some five years after, with a 
slight appearance of a return of the tumor. It, however, did 
not seem disposed to increase rapidly ; and as she had no suffer- 



TUMOR OF HEAD. 



485 



ing from it, and her health was not affected, I did not feel 
disposed to interfere by another grave operation. I kept her 
under observation for a time, but finally lost si^ht of her. 

About ten years after this, I was consulted again by the 
father of the girl, in regard to the propriety of another operation. 
He informed me that she had since been married, and gone to 
California : that she was quite well ; that the tumor had par- 
tially returned, and that she was desirous of knowino- whether 
another operation could be performed. I advised her as before. 

In July, 1866, 1 learned the following particulars from her 
father. She was still living in California, and suffered no in- 
convenience from the tumor. It had slowly enlarged, until 
three years ago, since when it had undergone no material 
change. 



Case CCLXXYII. — Extraordinary Tumor on the Head 
of a Young Child removed by Operation. — The following case 
is thus described by Dr. J. C. 
AVarren : — "In the month 

of April, 1843, Mr. , of 

Dover, N.H., wrote to me to 
come to that place, to exam- 
ine a tumor on the head of 
his child. 

"The child was a nursing 
boy, eight months old, quite 
healthy : a week after his 
birth, a tumor of the size of 
a pea was discovered on the 
back part of his head. This increased pretty rapidly, and the 
father at once consulted the medical gentlemen in his vicinity. 
Some thought it solid, others thought it fluid ; some advised 
him to have it destroyed by caustic, and others to apply a liga- 
ture about it. The latter advice, being considered the most 
safe, was adopted : a ligature was tied around the base of the 
tumor where it sprang from the head, not tight enough, 
however, to strangulate it, but merely to irritate the skin on 
which it was applied, which of course produced no impression 




486 TUMOES. 

on the disease ; yet this application was continued for three 
months. 

" Not being able to visit the patient, I advised that the child 
should be brought to Boston. On the 3d of May, he was accord- 
ingly brought. 

^' On examination by Dr. J. M. Warren and myself, we found 
on the back of this child's head a tumor almost as large as the 
head itself, of a globular form. It was elastic to the touch, not 
undulating, nor sensitive to pressure. It retained the natural 
color of the skin, except where the arteries and veins ramified 
over it ; these vessels were enlarged, and their branches and 
inosculations presented a beautiful appearance : there was no 
pulsation. On moving the body of the tumor, it did not appear 
to adhere closely to the bone or periosteum. 

"From this examination, my opinion was that the tumor was 
of solid growth, supplied by the vessels of the skin and those of 
the occipito-frontal muscle ; that it was not malignant in char- 
acter ; that it might and ought to be removed. The operation 
was performed the day following. May 4, 1843, by Dr. J. M. 
Warren. 

" An incision was made into each side of the tumor, compre- 
hending skin enough to cover the wound, and the tumor readily 
dissected off from the bone ; six arteries were tied, and the skin 
brought together by strips of adhesive plaster. 

" On examination of the tumor, I found it to be covered and 
insulated by a complete coat of cellular texture. Being divided, 
it presented a very white, uniform, granulated texture, inter- 
rupted only by some irregular partitions of cellular tissue. The 
microscope discovered nothing beyond what has been stated 
above. The most remarkable circumstance about this tumor 
was its firmness, which was very nearly equal to that of fibro- 
cartilaginous texture. On scraping the cut surface of the tumor 
with a knife, an opaque fluid was obtained in considerable quan- 
tity, similar in appearance to turnip juice and to the fluid 
obtained by scraping a scirrhous tumor of the breast. 

"The wound, which was about five inches long, was found 
united almost wholly in two days after the operation. The child 
had no fever, nor any sign of indisposition ; but, on the contrary. 



TUMOR OF HEAD. 487 

expressed by its movements a feeling of relief from the encnm- 
brance it had so long borne. The child being so well, the pa- 
rents, on the third day, took it home to Dover, much gratified 
with the result of an operation which they had imagined to be 
more formidable in its execution, and more protracted in its 
consequences. 

Hemarhs. — " The mother attributed the growth to her hav- 
ing, when pregnant, accidentally stumbled over a basket of 
oranges ; the tumor resembling this fruit in its form. 

" The dissimilarity of this tumor to the texture from which it 
sprang would lead to the opinion of its being a cancerous for- 
mation. Its consistence, color, and the fluid obtained from it 
by expression, were most similar to the appearances in a scirrhus 
of the breast. On the other hand, its perfect insulation by a sac 
from the surrounding textures, the nature of the connection of 
this sac with those textures, and their perfectly natural condition, 
enabled me to assure the parents of this child that there would 
not be a recurrence of the disease." 

This case is interesting from its resemblance to another tumor 
which we occasionally see arising in the same situation, and 
Avhich springs from the interior of the cranium. Mr. Costello, 
in his " Cyclopaedia of Surgery," under the head of Encephalo- 
cele, gives a description of the disease, with drawings, one of 
which, with a broad base, resembles the present tumor. About 
the time that this case came under our care, a cliild was brought 
to our surgical infirmary, with a congenital tumor apparently of 
a similar character. It was examined by many surgeons, and 
supposed to be a tumor, springing from the cranium, of an en- 
cysted character. It was therefore decided to remove it. 

The operation was nearly completed, the dissection being very 
easy, when it was found that a small pedicle of the tumor pene- 
trated the cranium, or, in fact, came out from it, as the tumor 
proved to be an extension of the membranes of the brain. The 
pedicle was divided with great care, and means were taken to 
prevent any air from coming in contact with the interior of the 
sac, the skin being brought together over it at once. The pa- 
tient, however, died in a few days, with cerebral symptoms. 

In the case first related, it was thought possible that the dis- 



488 TUMORS. 

section might in some way interfere with the cranial cavity ; as a 
rim of bone could be felt quite round the circumference of the 
tumor, such as is not unfrequently seen where the tumor has 
lodged for a long time in contact with the cranium, and which 
always renders the diagnosis a little difficult. 



TmiORS IN THE PAROTID REGION. 

The tumors usually found in this region, either originate in a 
small gland placed over the parotid, or are embedded in its sub- 
stance, or are placed under its lower edge, which is expanded 
to form a coating over the tumor, making it necessary to dissect 
through that portion of the expanded gland before the tumor is 
reached. They are, for the most part, innocuous, and are re- 
moved without great risk, although somewhat vascular. The 
tumors of the parotid itself are of a serious character, often of 
a malignant nature, and then usually scirrhous. 

As to the practical question which is often raised, whether the 
gland can be removed without the ligature of the carotid, the 
result of my experience is this : The parotid gland has been 
removed by me in many instances, some of which are given 
below : in none of them was the carotid artery tied. In scir- 
rhous aifections, where the gland undergoes a gradual induration, 
the vessels are frequently pushed backward, as they were in one 
or two of the cases here given. 

In a case mentioned by Dr. J. C. Warren, the carotid was 
cut at the end of the operation. The vessel was secured, and 
the patient did well. In a second case for the removal of a 
scirrhous parotid, in which I assisted Dr. Warren, the carotid 
was divided and tied. Three days after, as the patient was 
straining at stool, the vessel gave way, and the blood struck the 
ceiling. He almost at once fainted ; and the friends were for- 
tunately cool enough to place a sponge in the wound, and to 
check the flow partially. Being called, I at once cut down 
upon the vessel in the neck, tied it, and stopped the further 
eftlision of blood. Berard, in his monograph on this subject, 
mentions many instances of removal of this gland without ligature 
of the carotid, and quotes a case of extirpation of the parotid 



PAROTID TUMOR. 489 

by my grandfather, Dr. John Warren, in 1804, removed with- 
out tying this vessel, — the facial nerve being divided, and the 
face paralyzed. The patient lived fifteen years afterwards, and 
died of a disease foreign to the glandtdar affection. 

The following cases are illustrative of the above facts, and 
also of some peculiarities in the nature of the tumors themselves : 

Case CCLXXVIU. — Parotid Tumor. Removal.— A 
young married woman entered the Hospital in April, 1857, with 
a tumor of the parotid gland of one year's duration. Eight 
years before, she had a tumor below and behind the right ear, 
which was very hard and occasionally painful : the integument 
was not discolored. At the end of four years, having attained 
the size of a robin's eo;cr it was removed. The wound, she 
thinks, never cicatrized ; and, in four months, the tumor, having 
re-appeared in the midst of the scar, was again removed. Its 
character was similar to the preceding, with the exception that 
the surface was nodulated. The wound healed as usual, but 
the cicatrix remained very red. In 1855 the tumor began to 
form about in the same pla.ce; and in 1856 was as large as a 
hen's Q^g, projecting an inch, with a nodulated and red surface. 
Beginning below the ear, it proceeded upward and forward to 
about half an inch in front of the meatus. 

On the first day of May, 1857, the patient being etherized, 
the diseased mass was surrounded by an elliptical incision. From 
the situation of the disease, the dissection was made very slowly, 
requiring nearly an hour for the operation. At the lower part 
was a firm adhesion to the fibres of the sterno-mastoid muscle, a 
portion of which was removed. At the upper part, it was neces- 
sary to carry the dissection down to the articulation of the jaw, 
below and behind the angle of which the disease descended deep- 
ly, rendering necessary the exposure of the tendon of the digas- 
tricus. On raising the tumor to continue the deep dissection, 
violent efforts at vomiting, difficulty of breathing, and convul- 
sive retchings from the traction exercised on the deep nerves, 
came on, so that it was necessary to desist, and destroy the small 
portion of the base of the tumor with the hot iron. A few lio-- 
atures were applied ; and the wound, measuring three inches and 

62 



490 TUMORS. 

a half vertically by two transversely, was covered by a wet 
cloth. The growth measured vertically three inches. The face 
w^as more or less paralyzed after the operation. 

She was discharged from the Hospital on the 18th of June ; 
all the disease being apparently removed, and the whole wound 
reduced to a diameter of one-tliird of an inch. In the middle 
of September following, a letter was received, saying that the 
patient remained well, and the wound was healed. 

Case CCLXXIX. — Scir7^hoiis Tumor of Parotid. Re- 
moval. — The patient was a farmer, 52 years old. Twenty-five 
years before, a tumor made its appearance in front of the ear. 
This imperceptibly increased, giving him no pain or inconve- 
nience until two months before the operation, when it was injured 
by a blow, and since then rapidly increased in size. The night 
after the blow, he perceived that there was some insensibility in 
tlie skin in front of the tumor. For some time, he had been 
unable to close the right eye. "Now there is an oval, promi- 
nent, even, well-defined tumor in front of the right ear, over- 
lying the ramus of the lower jaw, and occupying the position of 
the parotid gland. Its long axis is parallel with a line drawn 
from the angle of the jaw to the external angle of the orbit. 
Its greatest length is three inches, width two inches. Upper 
margin is on a level with the angle of the eye ; lower margin 
with the angle of the jaw ; posterior is overlapped by external 
ear. Integument is movable ; not discolored. Tumor is of 
firm consistence ; not tender on pressure ; not attached to bone, 
yet but slightly movable ; does not move with lower jaw ; can- 
not be felt in mouth. There is much numbness of cheek in 
front, and a dull, but not severe pain in the tumor itself." — 
Hospital Record. 

■ When the patient entered the Hospital, one or two glands in 
the neighborhood of the tumor were enlarged, apparently from 
the effect of some irritating application which had been made to 
it. Under treatment, these, with one exception, disappeared. 
He was extremely desirous of having the tumor removed ; and, 
on a consultation of the surgeons, it w^as decided that this should 
be attempted. 



MELANOTIC TUMOli OF PAROTID. 491 

The patient beini>: etherized with chloric ether, an incision was 
made from just above the superior border of the tumor to a little 
below its inferior part. This was crossed by another incision, 
commencing at the mastoid process, and terminated on the cheek. 
The fibrous capsule of the gland was now cut into, and the tumor 
gradually loosened by dissecting carefully around its circumfer- 
ence. Its adhesions were so close and the texture so firm, that 
it was found impossible to proceed except with great caution ; 
the vessels that were divided under the edges of the tumor being- 
secured with much difficulty. The tumor was first loosened 
from its attachment to the zygomatic process, then dissected 
from the masseter muscle ; the transverse facial artery and the 
parotid duct being divided at this stage of the dissection. It 
was next detached from its firm adhesions to the sterno-mastoid 
muscle and mastoid process, and its adhesions to the ear cut ofi". 
Finally, by means of the blade and handle of the knife, it was 
separated from the great artery and vein which lay embedded 
in its posterior wall, the latter being cut and tied. Four or 
five arteries required ligatures. An enlarged gland in the neigh- 
borhood was removed separately from the tumor. 

The mouth was found paralyzed after the operation. The eye, 
which the patient was unable to close before, either in sleep or 
when awake, was found, a few days subsequent to the removal 
of the tumor, to drop down, so as partially to cover the eyeball 
when he was asleep. 

An examination of the tumor, after its removal, showed it to 
be tlie parotid in a scirrhous state ; the microscope disclosing an 
abundance of cancerous cells : with it was included a lymphatic 
gland embedded in its lower and under portion. 

The presence of the parotid duct and the facial nerve in the 
tumor, together with its anatomical relations, left no doubt as to 
the organ diseased. 

Case CCLXXX. — Melanotic Disease of the Parotid 
Gland. Operation by Ligature^ cutting, and freezing. — A 
seaman from Maine, unmarried, 25 years of age, entered the 
Hospital in 1852 with a melanotic tumor. For three years 
before, he had had a small black fungus upon the right cheek, 



492 TUMORS. 

in front of the ear, and the glands of the neck became some- 
what uTitated. 

At the time of liis admission, there was an irregular, lobular 
tumor, the upper part of which was surmounted by a black fun- 
gus as large as a walnut, occupying the right parotid region, 
where it was slightly movable, descending below and behind the 
angle of the jaw, where it was immovable. 

The patient being fully etherized, the tumor was surrounded 
by an elliptical incision, and the dissection commenced. Blood, 
however, followed every stroke of the knife, and poured from 
the whole surface of the tumor, so as only to be checked, and 
the further prosecution of the operation allowed, by applying 
the freezing mixture, and constant compression of the carotid. 
After the removal of some easily detached portions, by the ad- 
vice of the surgeons present, the operation was finally terminated 
by transfixing it at the base with a very strong double ligature, 
and tying it in two segments. Before this, many ligatures were 
placed on bleeding vessels, and the hemorrhage was very great. 
Wherever the tumor was cut or broken, a great amount of 
thick granular fluid, of a jet-black color, flowed out. 

Upon partial recovery from the effect of the ether, hemor- 
rhao^e from the tumor continued to such an extent as to render it 
necessary to again encircle the base by a strong ligature. The 
tumor ultimately returned. 

Case CCLXXXI. — Farotid Tumor. Removal. — A 
married man from Xova Scotia, b^ years of age, entered the 
Hospital in April, 1854, with a parotid tumor of twenty-six 
years' standing. It was situated on the left side, and extended 
downward, lifting up the lobe of the ear, partially closing the 
meatus, and causing some deafness. The integument over it 
was injected, but not adherent. The pain, for a short time, 
had been severe, preventing sleep. It was considered of so 
formidable a character, that the surgeons to whom he had applied 
declined interfering with it. 

The patient being etherized, the tumor was removed by a 
crucial incision through the skin, followed by a careful dissection, 
terminated without the ligature of the carotid artery. The hem- 



PAROTID TUMOR. 493 

orrhage was very free ; and the dissection could only be prose- 
cuted by stopping from time to time, and applying a freezing 
mixture of salt and ice, so as to allow an inspection of the parts 
to be divided. It was found to consist of hypertrophied gland- 
ular tissue. 

In a short time, he was discharged well ; and, when heard 
from, on Nov. 6, 1856, was in good health. 

Case CCLXXXII. — Cancer of the Parotid. — A woman, 
37 years of age, applied to me in the month of November, 1853, 
with a tumor occupying the seat of the parotid gland. It had 
appeared first, two years before, in front of the ear ; and, in its 
increase, had extended downward and under the ear, lifting up 
the lower part of that organ. It was a little movable, and did 
not project much beyond the surrounding parts. It appeared 
firmly attached below, was somewhat lobulated, and imparted a 
sense of elasticity to the touch. Her father died of cancer. 

The tumor was exposed by a careful dissection ; but, on its 
investments being cut into, a granular matter, like cancer, exuded 
from it, and the hemorrhage was very violent, welling up, as if 
from the carotid or some very large vessel. It was therefore 
found necessary to terminate the operation by the ligature en 
masse, as in the case of the melanotic affection. 

The disease, examined under the microscope, exhibited well- 
marked cancer-cells. 

I learned that she died subsequently of a tumor of the ab- 
domen. 

Case CCLXXXIII. — Tumor of Parotid. Pemoval. — 
A lady applied to me on June 18, 1859, on account of a tumor 
of the parotid gland. She was. 43 years of age, and enjoyed 
fair health, although dyspeptic : none of her family, that she 
was aware of, had ever been affected witli tumors. About two 
years before, she perceived a small swelling over the ramus of 
the upper jaw, just in front of the external meatus of the ear. 
She supposed it, and so did others, to be a tumor proceeding 
from the bone. During 1858, it increased much more rapidly 
than in the year before ; and she was finally induced, by the 



494 TUMORS. 

advice of her physician, although extremely nervous in regard 
to it, to apply to me for advice. 

The tumor then was about the size of a hen's egg, placed 
nearly over the articulation of the jaw, and extending to the 
malar bone. It did not extend down behind the jaw, elevating 
the lobe of the ear, a direction most of these tumors are disposed 
to take. It was perfectly solid and immovable, and, in any 
other situation, might have been taken for a disease placed 
between the periosteum and the bone, so firmly was it fixed. 
It did not partake of the motions of the jaw, which moved 
independently of it. There was no pain attending it. The 
patient was deaf on that side, which she attributed to pressure 
of the tumor on the auditory passage. As it was increasing, 
with the probability of taking a deep direction, and as it seemed 
limited to that portion of the parotid more superficially situated, 
I advised an operation, at the same time informing her friends 
that there was a possibility of its recurrence. I said possibility, 
rather than probability, because I have once or twice seen tu- 
mors of this description which were completely limited to the 
parotid capsule, and of an almost osseous firmness, removed 
without recurrence. The patient and friends having agreed to 
an operation, it was performed on June 24th ; one or two gentle- 
men who assisted at the operation thinking, from the firmness of 
the tumor, that it must be an enchondroma. 

An incision beino^ made over the whole lenc^th of it, and 
crossed at right angles by another, the entire tumor was exposed 
by dissection. The parotid capsule being next cut into, allowed 
a granular matter to escape, having the appearance of colloid. 
The dissection was now commenced in front and outside of the 
capsule, which was gradually dissected and peeled up with the 
knife and fingers, so as to remove it cleanly from the bone, 
and thus allow the delicate capsule of the upper jaw to escape 
uninjured. The facial nerve was seen emerging from the gland, 
and it was at first supposed that it would be necessary to di- 
vide it : it was afterwards found possible, however, to split the 
tumor transversely, dissect out the nerve, and leave it unin- 
jured, with the exception of one or two of the branches proceed- 
ing to the upper part of the face. The deep part of the gland 



PAROTID TUMOR. 



495 



which insinuates itself back of tlie lower jaw seemed to have 
escaped disease; a fact which I have once or twice observed, 
and which has been frequently observed by other surgeons. The 
bone, on which the tumor lay, had ahnost the aspect of being 
hollowed out by it. The wound was brought together by sutures, 
and cold water-dressings applied to it, with a little compression. 

The patient recovered rapidly, the skin adhering closely to the 
bone, so as to leave quite an excavated look to that part of the 
fjice. There was no facial paralysis ; but the muscular action 
above the orbit, on the right side, seemed lost from the section 
of the nerves distributed to that part, and was in sti'ong contrast 
with the muscular activity displayed on the opposite temple. 

This patient died about eighteen months after, from cancerous 
disease attacking the integuments of the face, in front of the 
former affection, with attendant constitutional disease. 

Case CCLXXXIY. — Parotid Tumor. Removal. — A 
healthy looking old woman, 64 years of age, came under my 




care at the Hospital, June 3, 1851. Thirty-two years before, 
she had the mumps on the right side of her face ; and, when 



496 TUMORS. 

the swelling subsided, a permanent tumor was left, which gradu- 
ally enlarged. In ten years, it had attained the size of a small 
orange ; and a female cancer doctor was applied to, who " drew 
it out," leaving an open sore. When this healed, the tumor 
again enlarged, and after 1849 grew rapidly. 

When I saw her, a tumor, such as is represented in the wood- 
cut, occupied the right side of the face and neck. The diameter 
of its base was five inches in one direction, and four in the other. 
Its circumference about the base was a little more than a foot. 
It was somewhat lobulated, and very elastic : the skin of it was 
rather strongly marked by veins, and scarred by the applications 
of caustic. It was freely movable on the subjacent parts, and 
caused a sense of uneasiness, rather than pain. 

The patient being etherized with chloric ether, two vertical 
incisions, semilunar in shape, were made over the tumor, includ- 
ing the circumscribed skin, which was adherent. Then, com- 
mencing at its lowest part, it was partly dissected, and partly 
peeled out. Its adhesions to neighboring parts were not very 
firm ; but it was exceedingly vascular, and the operation was 
frequently interrupted to tie vessels. The jugular vein was 
wounded, and the sound of air entering was distinctly heard. 
Tlie vein was severed, to prevent further ingress of air. At this 
time, she became quite faint from loss of blood. 

After the removal of the tumor, the carotid artery was found 
exposed at the bottom of the cavity. The remaining skin was 
not sufficient to cover the wound, which was therefore filled with 
lint. 

During the operation, parts of the tumor were so soft as to 
be pressed out between the fingers. This matter was nearly 
flesh-colored, and of the consistency of a soft apple. 

On cutting into it, the section was found composed of similar 
matter in part, but in some places was quite fibrous. Under 
the microscope, no true cancer-cells could be found : it ap- 
peared to be composed of fibres, with granular matter inter- 
spersed. 

The wound granulated rapidly, and healed without any un- 
toward symptom. 



RECURRENT PAROTID TUMOR. 497 

Case CCLXXXV. — Recurrent Tumor of the Parotid 
Gland. — A large, powerful, full-blooded man, 34 years of 
age, consulted me. In March, 1847, for a tumor in the right 
parotid gland. A tumor had been removed from the same spot 
twenty years before, which shortly afterwards re-appeared in the 
form of a small hard tubercle under the ear. For fifteen years 
it remained stationary, and then began to increase. 

It was about the size of a hen's-egg, of a bluisli color, lobu- 
lated, and having a hard base surrounded by small cysts. The 
lobe of the ear was pushed upward by the tumor, which ex- 
tended inward, and apparently Involved the lower half of the 
parotid gland. The patient was very desirous of an operation, 
and I determined to attempt its removal without first applying a 
ligature to the carotid, which seemed to be involved in it. Drs. 
J. C. AYarren, George Parkman, Samuel Parkman, Dr. Brigo-s, 
and Dr. D. D. Slade, were present at the operation. This was 
one of the early cases of the use of ether, which was adminis- 
tered by Dr. Morton with his apj^aratus. The tumor re- 
quired a very slow and careful dissection. The base of it was 
ossified , and pressed upon the facial nerve ; and this had caused 
a partial paralysis of that side of the face. The removal of it 
was accomplished without tying the carotid artery ; and the 
patient was sufficiently recovered in a week to return home, a 
distance of some hundred miles. 

Some twelve or fifteen years after, this patient again applied 
to me with a tumor in the same situation ; the face partially 
paralyzed on that side, the paralysis increasing as the tumor 
became harder. 

The tumor was again removed, the wound healed, and the 
patient remained well for a time. A few years afterwards, he 
applied to me a third time, and came into the Hospital, with a 
large ulcerated cancer, which had returned in the same situation. 

On consultation, it was decided that no operation was advis- 
able. The patient, however, was so solicitous that I should do 
something, that I dissected back the flaps of skin at the base of 
the tumor, and then passed two double ligatures, the size of a 
whipcord, by means of long needles with handles, at ri^ht 
angles, as far beneath the tumor as possible. The ligatures w^ere 

63 



498 TUMORS. 

then tied, and the whole mass strangulated. After it separated, 
powerful caustic applications were made ; and the man, when I 
last saw him, had a small healthy wound, in place of the oiFen- 
sive tumor which he w^as suffering from before the operation. 
This tumor therefore, from its commencement to the last opera- 
tion, had a course of between thirty and forty years. During 
the whole of this period, his general health was good. 

Case CCLXXXVI. — Remarhahle Disappearance of an 
A.pparent Scirrhous Tumor of the NecTc. — December, 1866. 
A gentleman, about 50 years of age, of spare habit and in deli- 
cate health, applied to me, about two years since, with a hard 
tumor of the size of a large hen's ^^,^^ situated partly under the 
ear. It w\as almost entirely enveloped in the substance of the 
sterno-mastoid muscle, w^iere it is attached to the mastoid pro- 
cess of the temporal bone. 

The tumor was ovoid, well defined, and apparently firmly 
fixed to the bone : the skin above it was a little discolored. 
There was no tenderness in it, and no marks of an active inflam- 
matory character. The patient said that it began, about six 
months before, in the substance of the muscle, and had gradu- 
ally grown to the above-mentioned size. 

I had no question, from the appearance of the patient and 
from the examination of the tumor, but that it was of a malig- 
nant character. I did not encourage its removal, as it involved 
a loss of skin and a large portion of the muscle, and a dissection 
from the bone, wdth every probability of recurrence. The pa- 
tient was much averse to an operation, unless I could promise 
him a perfect certainty of cure from it. I advised him some 
constitutional remedies to invigorate his health, and especially 
to avoid having the tumor handled or disturbed, as I have often 
seen the growth of tumors accelerated by repeated manipula- 
tions. 

Within a few days of writing this, a gentleman stopped me in 
the street to thank me for the advice I had given him, and re- 
called his case to me. He said that, shortly after consulting me, 
the tumor began gradually to disappear, and finally was entirely 
absorbed. On examining the spot occupied by it, I found the 



TUMOR or CHEEK. 499 

upper part of the sterno-uiastoid muscle sllglitly bulbous, as if 
inflated with air. The part, however, was perfectly soft, and 
not the slightest trace of the tumor remained. 

Case CChXXXYU, — Tumor of the Face and Orbit. 
Hecovery. — The patient was 40 years old. Fifteen years be- 
fore, a small pimple, followed by a scale, appeared on his face, 
below the eyelid. This was kept sore and irritated by being 
constantly picked. It slowly increased, invading the integu- 
ments of the face, cellular membrane, muscles, and apparently 
the malar bone, and taking partial possession of the orbit, so as 
to force the eye backward and upward, and in a great measure 
conceal it. The tumor appeared perfectly fixed, as if involving 
the malar and other bones of the orbit ; and the operation was 
done after stating to the patient the uncertainty of the result, of 
which he seemed fully aware, and with the expectation of the 
necessity of removing the malar bone and the obltar process of 
the superior maxillary. 

The tumor on the face being circumscribed by an incision, and 
the dissection commenced, it was found possible, while using the 
chisel to examine the state of the bone, to peel up the tumor 
with it from the base without removing any of the bone itself. 
The disease evidently had taken hold of the covering of the 
bone, but had not penetrated its structure. With much diffi- 
culty and patient dissection, the whole periosteum of the malar 
bone, wdth the tumor attached, was removed, and the dissection 
carried deeply into the orbit, removing the disease there in the 
same way; the whole mass coming out perfectly clean and 
smooth. The edge of the eyelid and the mucous membrane 
were left; and the sight was not injured, although the eyeball 
had been much compressed and forced from its natural position. 

A microscopical examination of tlie disease, afterward, by 
Dr. Ellis, revealed a structure composed of much fibrous tissue; 
but no cancer-cells could be detected. The patient recovered 
well after the operation. 

Case CCLXXXYIII. — Recurrent Tumor in Cheeh, with 
Erectile Tissue. Removal. Recovery. -—A young gentle- 



500 TUMORS. 

man from Halifax, N.S., 16 years old, came under my care in 
January, 1847, for a tumor situated in the substance of the 
right cheek. One of a similar nature had been removed from 
the same situation two years before, but had speedily re- 
turned. 

When I saw him, the whole of the right side of his face 
looked larger than the left. The veins were much distended ; 
and, at first sight, a malignant disease of the antrum would 
have been suspected. A lobulated tumor was found deeply 
seated in the substance of the cheek, just below the zygomatic 
arch, and apparently extended up under it. It was movable and 
hard. A large vascular polypoid growth occupied the right 
nostril, and entirely obstructed the breathing on that side. 

In consultation, it was determined to remove the tumor, 
which was done on Jan. 28th. This was one of the early 
cases of the use of ether, which was exhibited by Dr. Morton 
with his inhaler; and, in four minutes, the patient was quite in- 
sensible. The polypoid growth in the nose was first removed. 
A transverse incision was then made along the lower edge of 
the zygoma ; the skin and muscular substance cut through, 
which exposed an erectile tissue entirely enveloping the tumor, 
and intimately connected with the surrounding parts. In divid- 
ing this, in order to arrive at the body of the tumor, a hemor- 
rhage began, which greatly obscured the dissection ; and it was 
only by compressing the carotid that the operation could be 
continued. The tumor was now discovered extending up under 
the zygomatic arch, but only attached there by a loose cellular 
tissue ; behind, it dipped down in the direction of the spheno- 
maxillary fissure. It was detached from these different con- 
nections after a long dissection. The operation was suspended 
from time to time, in order to allow the repetition of the ether, 
which was three times repeated, at the request of the patient. 
He said subsequently, that he had experienced no pain, and that 
his impressions were agreeable. His call for ether, he said, was 
partly from the pleasure of taking it, and not entirely on ac- 
count of the relief it aflforded him from sufferino;. 

In consequence of the great hemorrhage from the whole sur- 
face of the wound, it was found necessary to use compression 



LEUCOCYTH^MIC TUMORS. 501 

with sponges. No subsequent bleeding took place, and the pa- 
tient recovered without any bad symptom. One or two weeks 
elapsed, however, before the sponges could be extricated from 
tlie deep wound, so firmly were they embraced by the granu- 
lations ; and at length removal was only accomplished by tear- 
ing them away piecemeal. The disease appeared to be of an 
encephaloid character, and entirely surrounded by erectile tis- 
sue, the division of which gave rise to the hemorrhage. With 
the exception of the actual cautery, the use of sponges seemed 
to me the only means of stopping the flow of blood ; and 
from the great difldculty in removing these from the wound, 
I think, that, in a similar case, I should give the preference to 
the former. 

Notwithstanding the malignant appearance of the tumor, the 
patient entirely recovered ; and I saw him some years afterward, 
grown to robust manhood, with a marked evidence on his face 
of the severity of the operations he had undergone. 

This disease was doubtless a polypoid growth, invested by 
erectile tissue. The question of its malignancy was settled by its 
not recurring. 1 have seen one instance of a similar growth 
which had made its way out from the posterior nares into the 
zygomatic fossa, probably by absorption of the superior maxil- 
lary bone ; a part of it appearing in the nostril of the affected 
side. 

LEUCOCYTH.^MIA . 

This subject has been already alluded to in the introduction to 
this chapter. Its history has been well illustrated by Dr. H. F. 
Damon of this city, in his "Prize Essay" published in 1864. 
An excellent paper on the "Policy or Impolicy of removing 
Leucocythaemic, Glandular Tumors," by Dr. D. AA". Cheever, 
was published in the Boston " Medical and Surgical Journal " 
for Aug. 2, 1866. 

I have had two or three cases of leucocythaemic growths, where 
the tumors were so extensive — occupying one or both sides of 
the neck — that an operation seemed unadvisable. These cases, 
of which the following is an example, have been much benefited 



502 TUMORS. 

by the use of iron, sea-bathing, a highly nourishing diet, and 
the other means usually employed in patients called scrofulous, 
or of other diseases of low vitality. 

Case CCLXXXIX. — Tumor of N^eclc. — A young woman, 
18 years of age, with scanty menstruation, and always of a 
delicate constitution, four years before I saw her had a small 
tumor appear in tlie neck, under the left ear. This, for about 
two years, seemed to increase and diminish at intervals. At the 
end of this time, the tumor began to grow larger ; and others 
were added to it, until the whole side of the neck, from the ear 
to the clavicle, was filled with large, soft, and easily moved 
tumors. These, upon any excitement, became enlarged, and 
tightly distended with blood. The patient was moderately 
fleshy, but had a livid, unhealthy look ; was troubled with pal- 
pitation of the Iieart, and debiUty ; also shortness of breath 
on slight exertion. She suffered no pain in the tumor, which 
seemed to dip deeply into the neck, and overhang the clavicle ; 
but she had neuralgia in the left arm, which was somewhat 
swollen. Her general health was improved by a tonic course 
of treatment, but the tumor did not diminish in size. 

Case CCXC. — Tumor of N'eck. Operation. Internal 
Jugular Vein cut and tied. Recovery. — A gentleman, 37 
years of age, applied to me in May, 18G1, for an ulcerated 
tumor on the left side of the neck, occupying the greater por- 
tion of the region between the outer part of the sterno-mastoid 
muscle and the trachea. A tumor of three years' growth had 
been removed from this spot in May, 1859. The sheath of the 
great vessels had been exposed, and the mass separated at that 
point, the pedicle apparently extending in between them nearly 
to the cervical vertebrae : a ligature was tied around this pedicle 
before the mass was cut off. The tumor was of an encysted 
character, and contained a thick fluid. The wound healed well, 
but shortly afterward the tumor began to re-appear. 

When he consulted me, it not only occupied a good part of the 
left side of the neck, but pressed back into the throat and on the 
trachea, impeding deglutition and respiration. Although I was 



TUMOK OF NECK. 503 

extremely lm^yillillg to operate, yet, at the urgent solicitation 
of the patient to make an effort to save his life, I consented. 
The tumor was encircled by an incision extending along the 
lower edge of the jaw ; another in front of the tumor, between 
it and the trachea ; one below, in a line with the clavicle ; and a 
fourth in a line with the sterno-mastoid. The operation required 
a long and laborious dissection of nearly two hours. In dis- 
secting the tumor from the great vessels, the internal jugular — 
which was partially incorporated with it — had a piece necessar- 
ily cut out from its side. The aperture in the vessel being seized 
with two forceps, a ligature closed the aperture. The tumor, 
which was of a dumb-bell shape, expanded behind the great 
vessels ; and that portion which pressed up the mucous mem- 
brane of the pharynx, and could be seen in the mouth, was 
removed without any great difficulty, no inflammatory adhesions 
binding it. 

The patient supported the operation well, being seated in a 
chair, and under the influence of ether for over two hours. The 
symptoms that followed were not any more violent than could 
have been expected from such an operation. He was kept ex- 
tremely quiet for a number of days, for fear of hemorrhage from 
the jugular. There was much soreness of the throat, and some 
aflection of his voice. But he recovered rapidly, and was well 
enough to return home to another State on the 28th of May, 
about three weeks after the operation. 

Dr. Calvin "Gv Ellis kindly gave me the following microscopic 
appearances of a portion of the tumor sent him : — 

" The growth was about three inches in diameter, and composed of 
small lobules, clusters of Avhich appeared to be contained In cysts, 
which they quite filled. The color of these lobules varied with the 
number of bloodvessels contained within them ; some being nearly 
white, while others were of a deep-red color. These vessels, after 
reaching the periphery of the lobule, returned in the form of loops. 
The lobules were composed of delicate fibrous tissue, with small nu- 
clei, with, for the most part, comparatively small nucleoli. In some 
parts, these nuclei Avere quite irregular in form." 

One or two years afterwards, this patient consulted me for 
a recurrence of this disease, for which no operation was avail- 



504 TUMORS. 

able. His general health, since the operation, had been quite 
good. 

Case CCXCI. — Large Tumor of Face mid Neck. He- 
moval. Recovery. Recurrence after three years. Opera- 
tion. Death. — Feb. 12, 1848. A man, aged 47, applied to 
me with a tumor of two years' standing, occupying a good part 
of the left side of the neck. It began as a movable tumor near 
the angle of the jaw, and increased until it extended from the 
condyle of the jaw to within an inch of the clavicle underneath 
the sterno-mastoid muscle, and beyond the median line of the 
neck, forcing the trachea before it, and encroached upon the 
mouth, pushing the tongue over to the right side. The carotid 
artery was lost in the tumor. At a consultation, it was de- 
cided that an effort to remove the tumor should be made, al- 
though the entire extirpation of it was considered as doubtful. 
The patient being placed under the influence of ether, the re- 
moval was effected, after a long and careful dissection ; that 
portion of the tumor which projected into the mouth being enu- 
cleated without any difficulty. The carotid artery and jugular 
vein were buried in a deep fissure on the lower part of the tumor. 
After its removal, the anatomy of the whole neck was beauti- 
fully displayed, particularly the small muscles under the jaw, 
and the nerves of that part. The patient recovered rapidly, 
and, after a few weeks, left the Hospital well. The tumor had 
a solid base, with an innumerable quantity of cysts, which per- 
vaded its substance and covered its surface. I saw nothing of 
this man, until two years afterwards. He then had, in the 
middle of his neck, under the skin, a small movable tumor, about 
the size of a nut, which could be taken up between the fingers, 
and might have been easily removed by a few strokes of the 
knife : he, however, declined to have it done. I lost sight of 
him until the spring of 1851, when I was called to see him, and 
found him in the following: condition : The entire left side of the 
neck, together with the front part, as far as the clavicle and 
sternum, was occupied by an enormous tumor, covered with 
large veins, and extending up into his mouth. One part of the 
surface had ulcerated ; and, from this place, there had been 



TUMOR OF FACE AND NECK. 505 

repeated and severe hemorrhages. He thought he had lost, 
once or twice, nearly a quart of blood ; but this was probably 
exaggerated. 

Under treatment, the bleeding was momentarily stayed ; but, 
recurring again, and threatening his life, he was finally induced 
to be removed to the Hospital, where he could be carefully 
watched, and means instantly used on the return of the hemor- 
rhage. After a few days' treatment, he revived a little ; and, 
on a full consultation of the surgeons of the Hospital, it was 
decided to inform the patient, that, if he chose to have an opera- 
tion done, it was barely possible that his life might be saved. 
To this he at once consented. The following day, his strength 
having revived a little, sufficient to allow of an attempt to 
remove the tumor, it w^as done as follows, under ether. The 
account is condensed from the Hospital records : An incision, 
more than a foot long, w^as made over the tumor, through the 
skin, from the mastoid process to the opposite side of the neck. 
The tumor was now partly dissected, and partly enucleated 
with the fingers w^here it passed under the tongue. The 
principal adhesions were in the vicinity of the great vessels ; 
from the sheath of which the tumor had in the first operation 
been dissected, and which had since become completely in- 
corporated with it. There was no difficulty in dissecting out 
the carotid : but this was not so with rci^ard to the iuo-ular, 
which w^as involved in a mass of inflammatory material, and 
its outlines with difficulty distinguished. This vein was wound- 
ed, and the opening into it followed by a great gush of blood. 
It was at once seized, and tied on the side. The hemorrhage 
elsewhere w^as principally venous, coming from the large veins 
w^hich everywhere covered the surface of the tumor. The whole 
time occupied in sweeping out — if it can be so called — this 
great mass, was but a few minutes ; as, after the first incisions, 
every moment of time that could be saved was precious : the 
surface being so extensive, it was useless to stop to tie vessels. 

On the completion of the operation, the patient fainted ; but 
soon revived, on taking a few drops of the spirits of ammonia. 
The wound being closed and dressed, he was carried to his bed, 
and seemed pretty comfortable. Towards evening, he had a 

64 



506 TUMOKS. 

return of collapse, and died suddenly. He had, in the most 
determined manner, refused — after the operation, and also be- 
fore it — the use of diffusible stimulants, from having taken the 
pledge against intoxicating drinks. Substitutes were used, but 
ineffectually ; and it is doubtful whether any thing would have 
altered the result. 

Case CCXCII. — Large Encysted Thyroid Tumor of the 
Neck. Incision. Hecovery. — A hale, hearty old lady, aged 
56, entered the Hospital on June 11, 1860, with a large tumor 
occupying the whole front of the neck, extending from the chin 
to the sternum, projecting out beyond the chin in front. It was 
evidently a sac, but so distended that at first it might easily be 
mistaken for a solid tumor. It began in the middle of the neck, 
when she was only two years of age, and increased slowly until 
June, 1859. Since then, it had nearly doubled in size. The 
skin over it was red, but moved freely on the subjacent parts. 
It was not translucent, and no fluctuation could be felt in it. 
There w^as no anaemia. She complained of fulness in the head, 
apparently owing to tlie obstruction of blood from pressure on 
the great vessels. On the 13th of June, I punctured the tu- 
mor wdth a small trocar, and drew off twelve ounces of dark, 
thin, chocolate-colored fluid. The canula was left in the w^ound ; 
but it escaped in the night, owing to the want of apposition be- 
tween the w^ound in the skin and the sac, after the escape of the 
fluid. I did not make an incision into the tumor at this time, 
wishino: first to test the hemorrhagic tendencv in it ; as I had 
once or twice before observed, in these cases, that, after the 
pressure of the fluid was taken off from the internal part of the 
sac, a troublesome bleeding took place from the erectile tissue 
pervading it. On the 20th of June, I made a free incision into 
the tumor, on the median line, and evacuated several ounces of 
bloody serum. A tent was then introduced, and retained in 
position by adhesive plaster. On the 21st, the patient was 
comfortable, but had a slight sensation of giddiness. The dis- 
charge was of a purulent nature, and gradually increased, from 
day to day, in quantity, becoming very offensive ; so that on 
June 30th, finding her suffering from great prostration and diar- 



THYROID TUMOR. 507 

rhoea, 1 again freely incised the sac, and covered it with a large 
poultice. She was then put upon a course of quinine. On the 
2d of July, there was considerable hemorrhage from the Avound, 
which was checked by exposure to the air. On the following- 
day, another slight hemorrhage took place, and a third one on 
the 6th July. Suppuration was free from the sac, and of a 
natural consistency. After this time she improved, and, on 
July 10th, was advised to leave the Hospital, and go into the 
country. I did not hear from this patient again until Nov. 24th, 
when her physiei;ui wrote me "that the tumor had entirely dis- 
appeared, and the wound healed up." 

Case CCXCIII. — Thyroid Tumor. Twice removed. — 
A woman, 35 years of age, noticed, in October, 1849, a small 
swellins: in the neck on the rio-lit side of the trachea. In No- 
vember, 1851, this having become very painful, I removed it, 
after a long and careful dissection. It proved to be a cyst in 
the right lobe of the thyroid gland. Four months after, another 
tumor appeared in the same situation, and slowly increased until 
May, 1858, when it was the size of an apple. It was fluctu- 
ating, and unaccompanied by pain ; but respiration was im- 
peded by its pressing on the larynx. 

The patient being etherized, a vertical incision was made over 
the tumor down to the sac, which was then laid open. About 
eight ounces of a dark-brown fluid escaped. Considerable 
hemorrhage ensued from the interior of the sac, proceeding from 
vessels which it was found impossible to secure. A strong liga- 
ture was therefore applied to the mouth of the sac, and the 
patient removed to her bed. It was found that the sac occu- 
pied the position of the right lobe of the thyroid gland. 

The sac at once filled again, and the ligature which confined 
the mouth of it threatened to give way, but fortunately did not 
until suppuration took place. For five days after the operation, 
there ^vere repeated hemorrhages from the superficial vessels, 
which were greatly engorged, and which were checked by the 
application of a solution of the perchloride of iron. The suppu- 
rative process obliterated the sac, and she was discharged per- 
manently cured in four weeks, and I have seen her frequently 
since, in good health. 



508 TUMORS. 

Thyroid tnmors, as surgeons well know, are always trouble- 
some to deal with. The treatment by seton is not unattended 
with danger, and I have seen serious hemorrhages result from 
its use. In one patient, a very marked protrusion of the eyes 
(exophthalmos) co-existed with it, accompanied by an anaemic 
condition and some cerebral disturbance. This patient urgently 
desired an operation, but I did not see the way clear to justify 
me in interfering with the tumor. The treatment of these tu- 
mors, whether solid or encysted, with the long-continued internal 
or external use of iodine, requires judgment and caution. 

Case CCXCIV. — Tumor of the Nech, involving the A.xil- 
lary Plexus of Nerves, Hemoval, — A woman, 40 years of 
age, applied to me in October, 1865, for a peculiar-looking 
tumor of the neck, of thirteen years' standing. Some time be- 
fore, she had been run over. A horse struck her with his head, 
knocking her down, and the wheel of a carriage passed over her 
shoulder. Shortly after the accident, a small hard tumor ap- 
peared, above the left clavicle, very near the acromion. This 
continued to 2[row until it attained the size of a oroose-eo^s^. It 
produced much pain in her arm, and partially paralyzed it. 
It lay very deep in the outer triangle of the neck, was a little 
movable, and slightly fluctuating on pressure. 

In order to remove it, a crucial incision was made so as to 
freely expose the tumor. This was composed of a thick sac, 
which was partially embraced by filaments and nerves of the 
brachial plexus. By a very careful dissection, the nerves were 
gradually detached from the tumor, and the sac dissected out, 
leaving the brachial plexus exposed. The hemorrhage was quite 
free, and some large vessels required the ligature. 

The sac contained a turbid, serous fluid. In the inflamma- 
tory process which ensued for the reparation of the wound, the 
pain in the arm was temporarily aggravated, accompanied with 
cramps in the thumb, index and middle fingers. 

She gradually recovered, and was discharged in about three 
weeks. I saw her some months afterward, and prescribed for 
her a number of times ; the power in the arm becoming grad- 
ually restored after the removal of the tumor. 



CYSTIC TUMOR OF BREAST. 509 

The exact way in which the passage of the wheel over the 
shoulder caused the tumor is difficult to explain, except that 
it was bj some effusion of blood at the time, under the fascia. 

Case CCXCV. — Hydrocele of the Neclc. Inflamma- 
tion. Suppuration. Removal of Sac. — A young man, 28 
years of age, had, for a year, a tumor in the lower triangle of 
the neck. It commenced quite small, just above the clavicle. 
When I first saw him, it had increased so as to occupy nearly 
the whole of one side of the neck ; extending from the clavicle 
to the mastoid process, and from the trachea, underneath the 
sterno-mastoid muscle, to the back of the neck. It caused him 
much pain, and, from the pressure on the trachea, difficulty ot 
respiration. By my direction, he entered the Hospital for 
treatment. Shortly after, it suddenly became tense and pain- 
ful, and the spot on its surface red ; showing indications of sup- 
puration. It was therefore opened, and a great quantity ot 
sero-purulent matter discharged. It had once before been 
opened, and a quantity of milky serum evacuated. 

The tumor now gradually contracted, and the patient had 
much relief. At the end of about three weeks, it had contracted 
to the size of a large apple, and it was determined to attempt to 
remove it. 

The dissection was very long and laborious, implicating most 
of tlie large bloodvessels and nerves of the neck ; the inflamma- 
tion, Avhich had taken place in the sac, having glued it to the 
surrounding parts. A symptom which occurred during its re- 
moval is worthy of notice, which I have observed before in 
removing important tumors involving the nerves of the neck. 
Whenever the tumor was dragged upon, respiration was so much 
affected that it was necessary to suspend the operation for a 
time. 

He remained quite depressed for an hour after the operation, 
although he lost but little blood. The recovery, however, was 
good. 

Case CCXCYI. — Cystic Tumor of Breast. Removal. 
— April, 1866. A stout, healthy-looking German woman, 45 



510 TUMORS. 

years of age, entered the Hospital for a tumor of the breast, 
of wliich she gave the following history : Eighteen years before, 
after her first confinement, she applied a puppy to her breast to 
draw off the milk. Instead of drawing off the milk, he bit off 
the nipple so completely that the milk could not be drawn at 
all. Soon after, the breast began to swell ; and, at the end of 
three months, broke. 

After this had healed, a small hard bunch was noticed in the 
substance of the gland, inside of the position of the nipple. 
With the birth of each one of her children subsequently, she 
had a similar abscess in the breast ; and the tumor slowly 
increased in size. During this period, her general health re- 
mained very good ; and she suffered no pain in the breast, ex- 
cept at the time when it was distended witli milk, and broken. 
In the early part of March, 1866, after exposure to severe 
weather, the breast became swollen ; and, to relieve it, she 
applied, by the advice of an old woman, a strong caustic prep- 
aration, which was kept on until three days before coming to the 
Hospital. 

On entrance, the breast presented the following appearances : 
It was very much enlarged, and the skin denuded for a space of 
six inches in circumference in the centre, where a pedunculated, 
ovoid, bleeding mass, the size of an orange, protruded. Inside 
of this, covered by the skin, a hard lump, the size of a hen's 
egg:, could be felt. The patient stated, that a small mass, 
attached to the larger one, had sloughed away five days before. 
She had no pain at any time, except from the use of the caus- 
tic. The skin of the gland, outside of the denuded portion, 
was not discolored. 

The patient being etherized, the tumors, with the surrounding 
gland- tissue, were removed. Very slight hemorrhage ensued, 
requiring four ligatures. The tumors were found to be com- 
posed of proliferous cysts. 

The wound united almost by the first intention ; and the 
patient left the Hospital, well, in the course of a few weeks. 

Case CCXCVII. — Urectile T^imor of Breast . JRemoval. 
— July, 1862, a healthy woman, 47 years of age, entered the 



TUMOR OF BREAST. 511 

Hospital for a tumor of the breast. It appeared, two years 
before, as a small, hard, painless lump in the right breast, near 
the nipple, and increased in size slowly. In June, 1862, after 
an examination, pain was first felt ; and for the following month 
there were, at times, severe lancinating pains in the breast, 
which was about double the natural size, and moderately hard 
on pressure. 

The patient was etherized, and the hardness entirely subsided. 
An exploratory incision was then made over the tumor ; and, 
after dissecting through the skin and adipose tissue, a dark-blue 
substance was found, which proved to be a mass of dilated veins, 
about the size of the little finger. The rest of the tumor was 
then carefully dissected out, and found to be of an erectile char- 
acter, occupying the entire gland. The whole mass was removed, 
a iew small arteries requiring ligature. The patient made a 
rapid recovery. 

Case CCXCVIII. — Chronic Inflammation of the Breast^ 
resembling Scirrhus. Removal. — A woman, born in Eng- 
land, apparently of Jewish origin, applied to me in January, 
1861, for a tumor of the right breast, Avhich, to the touch, gave 
the ordinary sensation of scirrhus. Her physician, a distin- 
guished practitioner in a neighboring town, had examined it, 
and advised its removal. She was twenty-five years of age ; 
with an extremely delicate and transparent skin. Her health 
had generally been good. She had been twice confined, and 
had had one or two miscarriages ; but, although well developed 
in every respect, never had any milk. Xine months before, she 
was confined, when a swelling took place of both breasts, but 
without any milk in either. The right breast suppurated, and 
was opened in two or three places : it remained in a sore state 
for two months, when it healed, leaving an induration. This 
enlarged from that time, and became more and more trouble- 
some. 

A tumor of the size of a small potato was discovered in the 
axillary side of the breast. It was quite movable : the skin over 
it was retracted, and adherent in one or two places ; the nipple 
so deeply drawn in as to have entirely disappeared. The tumor 



512 TUMORS. 

could not be distinguished from scirrhus : still, the history of 
the case and age of the patient seemed against it ; but as the 
breast was entirely useless, and as it was the source of great 
irritation to her, I advised its removal. 

The tumor was removed, together with the nipple and adher- 
ent skin. The body of the tumor was composed of a transparent 
fibrous tissue, which creaked under the scalpel. Near the sur- 
face was an abscess, about the size of a cherry, filled with 
unhealthy looking pus. Although, when exposed, the tumor 
still gave to the finger the sensation of scirrhus, yet, on examina- 
tion with the microscope, no cancer-cells could be found in it. 

The patient had a good recovery, and was seen, in March, 
1862, in a state of perfect health. 

Case CCXCIX. — Cancer of the Breast. Removal. — On 
the 27th December, 1861, I operated on the following case : The 
lady was 40 years of age, unmarried, and very delicate. One 
or two of her family had died of cancer of the uterus, and one 
now has a cancer of the breast. She perceived the tumor on 
the axillary side of the left breast four years before ; it then 
being quite small and movable. One year before, it enlarged, 
adhered to the skin ; and was just on the point of ulceration 
when I operated. She had pain in the tumor, and in the arm 
of that side. I removed the tumor, the mammary gland to 
which it was attached, and the skin over it. The wound was ap- 
proximated by sutures and adhesive straps, and a bandage applied. 

On cutting open the tumor, it was found to be a scirrhous 
lump, involving the edge of the mammary gland ; the skin over 
it being destroyed and the edges of the skin incorporated with 
it. The wound healed well. A slight irritation, and exudation 
from the surface of the scar, however, continued for some 
months. She then improved in health, and now, at the end of 
five years, is perfectly well. 

Case CCC. — Cancer of the Breast^ following immedi- 
ately on jSfursing. Palliative Operation, ivith Recurrence 
of Disease. — A lady was brought to me by her physician, 
with a scirrhous enlargement of the left breast ; the skin being 



CANCER OF BREAST. 513 

covered with cancerous tubercles. There was also a sli2:ht 
enlargement of the glands in the axilla. The tumor was quite 
painful, as was the arm of the same side, and sleep inter- 
fered with from this cause. There was also a sli^^ht couo^h. 
She was a small, rather delicate woman, forty-five years old, and 
the mother of eight children ; the dis'ease having appeared about 
four months before, immediately after weanins^ the last child. 
The operation for its removal was performed on the 7th of De- 
cember, 1861. The breast, with the skin over it, and the 
diseased gland in the axilla, being removed, sufficient integument 
remained to allow of the approximation of the edges of the 
wound. The hemorrhage was considerable, as is the case in 
most of these tumors of an active growth. As the woman was 
thin, I determined to make an attempt for union by the first 
intention : the edges of the wound were therefore nicely approxi- 
mated by means of sutures and plaster. For the first two or 
three days, she had a febrile action, apparently depending, in a 
great measure, on the effect of the ether. 

The wound united, almost by the first intention : a part of 
the skin, however, in its centre, where the traction was the 
greatest, sloughed. About the tenth day, she was able to sit up 
and take solid food, and on the fourteenth was able to go out 
for a short walk. Shortly after, she left the Hospital with her 
wound nearly healed, the pain relieved, and her cough entirely 
gone. 

I saw her again a few months after, with a recurrence of the 
disease in the cicatrix. I should have stated before, that I had 
informed the patient's friends, previous to the first operation, 
that cancer occurring in this way, either during or immediately 
after nursing, is generally of the most unfavorable description, 
and is almost certain to recur : If, however, they chose to have 
an operation performed, to relieve her sufferings and to give her 
a temporary respite, I saw no objection. The operation did 
have this effect, and also relieved her cough. Her health had 
been quite good after the healing of the wound. I did not 
advise a repetition of the operation, as I should have done 
under other circumstances. 

65 



514 TUMORS. 

Case CCCI. — Cancer of Breast while Nursing, Re- 
moval. — A lady, 26 years of age, of good shape, and always 
healthy, was delivered of her first child in 1859. In August, 
1860, she perceived that her right breast was swollen, but con- 
tinued to nurse, and in January applied to me with an infil- 
trated cancer of the whole of the gland. It did not then give 
her much pain, but her health was failing. I advised weaning 
her child at once. Subsequently, she came to me again, with 
the disease in an advanced state of development. The whole 
breast was solid, and might well be called scirrhous. The skin 
was covered with cancerous tubercles : there was an enlarged 
gland under the axilla. The pain in it was excessive, of a burn- 
ing, stinging character, and darting up through the nerves of 
the shoulder-joint. She was very desirous of having the dis- 
ease removed, and I finally agreed to do it, in order to give 
her a temporary relief; at the same time, making her fully un- 
derstand that that was all she could expect from it. When it 
came to the operation, her courage failed, and she determined 
to abandon the idea of having it removed. I did not see her 
again for two or three weeks, when she called on me, and said 
that the pain had become so intense, and of such a burning, 
grinding character, as to deprive her of sleep, and render 
life intolerable. She begged, therefore, to have the operation 
done ; otherwise, she feared that she should die from excessive 
pain. The whole substance of the breast, together with the 
skin, was of the most excessive hardness : it appeared solidly 
adherent to the ribs. The patient had a bluish and almost 
asphyxiated look, but was still in tolerable flesh, and was 
pretty strong. She was fully etherized, and the whole tumor 
encircled by an incision. A little dissection was now made 
under the lower edge of the mass, so as to afibrd a good hold 
upon it ; and the separation was completed, partly by tearing, 
and partly by the handle of the knife and the fingers ; this 
being considered the more effectual way of getting rid of the 
diseased tissue. The surface exposed was about the size of a 
common dinner-plate. The bleeding after the operation was not 
excessive ; but, while engaged in taking up the vessels which 
required ligatures, the pulse failed, and the patient was seen to 



CANCER OF BREAST. 515 

be in a state of collapse, requiring the application of ammonia to 
the nostrils, frictions, &c., under which treatment she revived. 
I have once or twice observed this condition, when extensive 
wounds over the region of the heart have been exposed to the 
air. In the present instance, these same symptoms recurred as 
soon as the whole surface of the wound was again exposed. The 
remaining vessels were therefore secured, taking care to uncover 
only a small surface of the wound at a time. In the subsequent 
dressings, instead of using cerate, flour was applied to the whole 
surface, which was removed from day to day, as appeared to be 
required. This method I have frequently adopted in dressing 
very large wounds resulting from the removal of the breast, 
when it is important to avoid the daily exposure of the surface 
in dressing. The secretions are absorbed by the flour ; and the 
small masses thus formed roll off" from the wound, and can be 
easily removed, and replaced by fresh applications. She was 
at once relieved by the operation, and was placed in a state of 
comfort, when compared with her previous condition of torment. 
It required three or four weeks for her to recover so as to be 
able to go home. The wound was then two-thirds healed. I 
never heard from her afterward, but have no doubt that the dis- 
ease returned. 

Case CCCII. — Cancer of the Breast. Operation. Re- 
appearance of Cancer in other p)ciyts of the Body. Repeated 
Operation. — A lady, 45 years of age, of fine development, 
who had always enjoyed good health, called on me in June, 
1858, with a tumor in the right breast, of a year's standing. It 
was evidently scirrhous, and was rapidly approaching the surface. 
I removed the whole breast. The tumor being large, many 
ligatures were required : the wound healed kindly, with the ex- 
ception of one spot, where there was much irritation, which, 
after five or six weeks, almost gave rise to the idea that there 
was a recurrence of the disease ; but this was finally relieved by 
the discharge of the knot of a ligature. In October, 1859, I 
was called to see her, to examine a large, hard, scirrhous mass 
in the axilla of the same side, of the size of a double fist, quite 
movable, but evidently implicating the nerves and the axillary 



516 TUMORS. 

artery. I advised an operation, and, after making the external 
incisions, removed the disease principally by enucleation with 
the fingers ; exposing all the great nerves, artery, and veins in 
the axilla. The patient remained quite v^^ell until August, 1860, 
when, after much fatigue from travelling, an ulceration oc- 
curred in the axilla, which I at first feared was a return of the 
disease, but which healed up kindly, leaving no induration. 
January, 1861, I was requested to see her on account of a 
swelling partly over the spinous process of one of the dorsal 
vertebrae. I at once detected a scirrhous lump there. She, 
at this time, was complaining of neuralgic pains in the left 
shoulder and axilla. The cicatrix of the breast and axilla was 
perfectly sound. The tumor at first seemed quite indefinite, but 
gradually, after some wrecks, became defined ; and, at her re- 
quest, I proceeded to remove it. The disease seemed almost 
confined to the fascia over the vertebrae, and came out in a solid 
disc of about the size of a dollar. It w^as about an inch thick 
in the centre, and tapered off towards the edges : the skin was 
not implicated ; and, after the removal of the diseased mass, 
the surrounding parts were found to be quite healthy. The 
wound healed well, and there was no return of the disease lo- 
cally. On the 11th of December, 1861, after complaining for 
two or three weeks of a sense of numbness, attended with neu- 
ralgic pains in the muscles of the thighs, together with a partial 
paralysis of the flexor muscles of the right thigh, she was seized 
with an epileptic convulsion, which lasted between one and two 
hours, in the course of which the right thigh was broken near 
its upper third. The cerebral irritation subsided during the 
course of the night, so that on the next day but little evidence 
of it remained. She did not, however, for a week after, com- 
plain of her broken thigh. I did not think it worth while to 
apply any apparatus to the limb, and she did not discover what 
had occurred, but simply placed it on a pillow; in which posi- 
tion, with the toes a little everted, it united in a couple of 
months. Daring this period, she had two or three epileptic 
attacks, whose violence was mitigated by the inhalation of ether. 
On the 7th of March, 1862, she had an attack which lasted the 
greater part of the night, leaving her mind in a wandering 



CANCER OF BREAST. 517 

state, in which condition she remained at the date of the present 
record (March 11th), recognizing friends with a smile, but 
suffering from an entire loss of memory. She has now a can- 
cerous tubercle under the skin, over the right scapula, and a 
cancerous mass in front of the left scapula, on the back. Dur- 
ing the whole of this long period, she has never had the slightest 
pain, and has submitted to the various operations with for- 
titude and resignation, and, in fact, was never aware of the 
exact nature of her disease. 

She sank shortly after, and died without suffering. 

Case CCCIII. — Recurrent Cancer. Long-continued Se- 
cretion of Milk. — I was requested in February, 1851, to see 
a woman, 64 years of age, from whom I had removed the left 
breast ten years before, for a cancerous tumor of two years' 
standing. She was then a widow, and her youngest child was 
35 years old. After weaning this child, she had milk in the 
breast which afterwards became diseased, for three years. She 
had remained well after the first operation until 1850, when two 
lumps appeared, one over the pectoral muscle, and one in the 
axilla; the former being adherent to the skin, and had been 
tampered with by caustics. These tumors were thoroughly re- 
moved. 

I saw her a year afterwards, in a good state of health, and 
with no return of cancer. ^ 

This patient had been subject, for many years, to obstinate 
constipation, often going sixteen days without an action of the 
bowels. This condition had lately been completely relieved by 
the use of a glass of wine daily, with a small quantity of the 
sulphate of magnesia in it. 

Case CCCIV. — Cancer of the Breast. Long-continued 
Secretion of Milk. — In 1852, I operated on a woman, 60 
years of age, to remove a small cancerous tumor of the right 
breast, of a year and a half standing. This patient had con- 
tinued to have milk in both breasts since the birth of her first 
child, thirty-seven years before. Her mother had died of can- 
cer of the breast, and one of her sisters of a cancerous ulcer- 
ation of the nose. 



518 TUMORS. 

In another instance, I removed a cancerous breast, in which 
the milk had been retained on that side for twenty years. 

Case CCCV. — Tumor of Male Breast. Removal. Re- 
covery. — A man, 63 years of age, entered the Hospital, June 
16, 1865, who, about four months before, had noticed a small, 
hard tumor, above and to the outside of the right nipple. 
For the first month after its appearance, the only sensation in it 
was one of itching. It afterwards rapidly increased in size, 
becoming softer, and at times painful. It was about the size of 
an egg, circumscribed and movable : there were no external 
signs of inflammatory action. He had generally been healthy. 

About fifteen years before. Dr. J. C. Warren removed a can- 
cer from his right lower eyelid. He said that an uncle of his 
had a large cancer on his lip, which destroyed him. 

The patient being placed under ether, the tumor was removed 
by two elliptical incisions. On examination by the microscope, 
it proved not to be malignant, but consisted of a hypertrophied 
glandular structure. The patient did well, the wound healing 
up very rapidly. 

Case CCCVI. — Remarkable Tumor in the Axilla, coming 
on after Nursing. — A delicate lady, about 30 years of age, 
after the birth of her second child, had a tumor, one and a quar- 
ter inches wide, and three inches long, appear in each axillary 
reo^ion as soon as the milk be^an to be secreted in the breasts. 
These w^ere oblong, flabby, and not unlike the breast itself in 
a flaccid state, but without any thing corresponding to a nipple, 
and were especially enlarged during lactation. On the milk dry- 
ing up, the tumors disappeared in a great measure, leaving, 
however, distinct rudiments in their site. At her next confine- 
ment, she was delivered of a stillborn child. The secretion of 
milk which ensued was attended with similar phenomena in the 
axillae, the swellino^ beins^ much ofreater on the rio^ht side than 
on the left. In addition, on the right side, a small, hard, light- 
gray tumor, of the size of a pea, formed upon the apex of the 
swelling. This soon became the seat of the most intolerable 
lancinating pains, particularly at the menstrual periods, attended 



TUMOR OF ARM. 519 

with a sympathetic affection of the other axilla, and similar pains 
of a severe character in the region of both ovaries. My friend, 
Dr. Charles G. Putnam, her physician, who has had a very ex- 
tensive experience in affections connected with pregnancy, had 
never seen any thing similar to this ; and he requested me to visit 
the case with him in consultation, thinking that possibly It might 
be one of the painful subcutaneous tubercles which are often so 
much aggravated during or preceding the puerperal state. The 
whole tumor seemed to be composed, first, of the flabby skin ; 
then of a collection of glands, so soft as scarcely to be distin- 
guished from the cellular tissue ; and, implanted in the apex, the 
small, hard, and painful tubercle just referred to. From my 
experience of the painful subcutaneous tubercle, often found 
in the extremities, I was confident that this tumor was not of 
that character, and determined to make an incision in it. When 
this was done, a quantity of milky fluid was projected with vio- 
lence a distance of several feet, and the tumor wholly subsided. 
On the following day, she was entirely free from pain. 

From that time, the neuralgic condition of different parts of 
the body, which seemed to emanate from this small cyst on the 
apex of the axillary tumor, ceased ; and she very rapidly re- 
covered her health. 

Case CCCVII. — Large Tumor of the Arm (see woodcut). 
This old lady, 75 years of age, informed me that, twenty years 
before, her husband, while in a state of insanity, threw at her a 
cannon-hall, which hit her on the arm, near the axilla. Shortly 
afterward, the tumor began to make its appearance, and in- 
creased until it attained an enormous size. It appeared to be of 
a fibro-cellular character, and of about twenty pounds weight ; 
hanging down so that, when the arm was held at a right angle 
with the body, it rested on the seat on which she sat, dragging 
down the integuments and other structures in its vicinity. Very 
laro:e vessels entered it from the axilla, and could be distino^uished 
pulsating in its substance. The tumor was carried by the pa- 
tient in a large sleeve ; and, when I saw it first, it had an ulcer- 
ation on the surface, caused by being projected from her sleeve 
upon the grate, while she was throwing coals upon the fire. She 



520 



TUMORS. 




had a second tumor, apparently of a similar description, on 
her face. 

A very striking daguerrotype was taken of this patient and 
the tumor. 

From some superstitious feeling connected with its removal, 
she declined having it operated on ; and it is principally from 
the manner of its occurrence, its apparent structure, and its 
uncommon size in this situation, that I have thought it worth 
while to relate it, and have it depicted. 



Case CCCVIII. — Enchondroma of the First Phalanx of 
the Middle Finger. Amputation. — May, 1850. The sub- 
ject of the disease was a girl, 13 years old. When two years 
of age, a small, hard swelling appeared on the inner side of the 



ADIPOSE TUMOR. 521 

first phalanx of the middle finger. This slowly increased, and 
produced no inconvenience, except from its size, which more or 
less interfered with the motion of the hand. 

At the time of the operation, the tumor was the size of a 
small apple, involving the whole bone of the first phalanx, and 
part of the second. The finger was forced out of its place, and 
lay diagonally across the little and ring finger. A small tumor 
• of similar description occupied the lower phalanx of the fore- 
finger. On the ring-finger was another, a still smaller one, 
lying under and concealed by the larger tumor. 

The finger was removed, and the head of the metacarpal 
bone sawed oflf to allow of the necessary approximation of the 
edges of the wound. 

A section of the excised part showed a uniform appearance, 
like the interior of a ripe apple. The periphery was somewhat 
elastic, like the more delicate layer of bone or cartilage. A few 
spiculae of bone were interspersed through the interior. The 
shaft of the bone had disappeared. The metacarpal extremity 
remained. 

Case CCCIX. — Case of large Adipose Tumor between 
the Thumb and Forefinger, — A woman, 73 years of age, 
entered the Hospital, April 6, 1865, for a tumor, the size of a 
billiard-ball, of thirty-five years' standing, grasped, as it were, 
between the thumb and forefinger of the left hand. AV^hen first 
noticed, it was the size of a bean, and increased until it at- 
tained the above dimensions ; becoming troublesome, and pre- 
venting the use of the fingers. The skin over it was thin, 
dry, and wrinkled. It was easily removed, peeling off readily 
from the muscles, and not involving any important vessels or 
nerves. The wound healed well. 

An adipose tumor in this situation is rare ; and I remember 
having seen only one other, which was in a child, and surrounded 
the first phalanx of one of the fingers. 

It had grow^n very rapidly, entirely enveloped the bone, was 
round, elastic, quite painful, and was supposed to be (after 
repeated examinations by experienced surgeons) malignant. An 
incision into it seemed to justify this opinion ; and it was de- 

66 



522 TUMORS. 

cided to remove the finger at the joint, which was done. On 
examination, it proved to be an adipose tumor, surrounding 
and clinging tight to the bone. The pressure of the tendons and 
fascia over it had compressed it in such a way as to give it the 
appearance of a cancer when explored. Amputation, hovv^ever, 
was the only remedy. The operation was not performed hastily, 
but after the patient had been under observation some time. 
The finger was accordingly amputated, but one vessel requiring 
ligature. 

Case CCCX. — Cystic Tumor of the Head of the Tibia, 
Ampiitatio7i. — A man, 33 years of age, came under my care 
in May, 1859. Eighteen months before, he feceived a severe 
blow on the upper part of the right fibula, producing an in- 
flammation and swelling there. After the first symptoms had 
subsided, a hard swelling Avas discovered, which gradually in- 
creased. In March, 1859, he said that the tumor was about 
half the size of an apple ; " that it had the elastic feel of a 
windgall," and seemed to him as if, with slight pressure, he 
could force in its walls like stiff paper. Blisters were applied to 
it, which inflamed its surface. In April, an issue was em- 
ployed, which made an opening into it, from which was dis- 
charged about half a teacup of clear serum, followed by more 
or less blood. 

When I first saw him, his general health was quite good. He 
was able to walk with some limping, the knee being very slightly 
bent. The upper and anterior part of the leg was occupied 
by a hard swelling, which entirely obscured the course of the 
upper third of the fibula. The surfece of the tumor was covered 
by an inflamed skin from the application of vesicating substances, 
in the centre of which was a small opening, obstructed by a 
slough. Upon pressure on the limb, a quantity of sero-puru- 
lent matter ran out. The forefinger, being insinuated very 
slowly and carefully into this aperture, traversed the tumor 
through a mass of loose granulated substance, and brought 
up against the tibia, which felt quite smooth, as if covered by a 
serous membrane ; and, the finger being swept around, en- 
countered an elevated cup of bone. The head of the fibula was 



CYSTIC TUMOR OF TIBIA. 523 

nowhere to be discovered ; and though, at one part of the tibia, 
a little roughness could be detected, no loose spiculae of bone 
were anvwhere to be observed. The lino-er beins; withdrawn, 
a slow stream of venous blood followed, and continued to flow 
for one or two minutes. 

I informed the patient of the nature of the disease, and that 
the only remedy was amputation, — an opinion agreed in by the 
other surgeons of the Hospital, who saw him on the following 
day. I myself rather inclined to favor the idea that the disease 
was what has been called spina ventosa ; and that the sup- 
puration of the tumor and the granulated contents were to be 
attributed to the inflammatory action brought on by the issue, 
thus giving it a 'malignant aspect, — an idea which some of the 
gentlemen favored. 

In addition to what has been stated above, in regard to the 
use of the limb, it may be added, that the power of flexion of 
the foot was entirely destroyed, so that it hung loose in walking ; 
a fact which was explained afterwards by the entire destruction 
of the bodies of the muscles by the pressure of the tumor. 

The operation was done on Saturday, May 14th. The pa- 
tient being etherized, the tumor was first slit open, in accordance 
with a promise made to him ; and, the upper part of the fibula 
being found to be destroyed, together with the muscles in front 
of it, amputation was at once proceeded to. In order to obtain 
a long stump, the first incisions through the skin were made 
just over the upper edge of the patella. There was very little 
hemorrhage, and not more than half a dozen vessels required 
ligatures. Four sutures were introduced in the flaps, but not 
tied, and the wound left open till the afternoon. 

The disease presented very curious and interesting phenomena. 
The skin, being dissected back, disclosed a large cavity, filled 
apparently with old coagula. These being removed, at the bot- 
tom were portions of the sac, of the color and consistence of 
that of an aneurism. The lower part of this sac was formed by 
the upper part of that portion of the fibula which had been left, 
three inches of it having been destroyed by disease. The por- 
tion alluded to was lined by a smooth membrane in its centre, 
expanded and rough on its edges. At the upper part of the 



524 TUMORS. 

wound was a small piece of the head of the fibula, about the 
eighth of an inch in thickness, which still remained attached to 
the head of the tibia. The inner part of the cavity was partly 
formed by the tibia, covered by a smooth membrane, as stated 
before, and seemed to be of a somewhat flattened cup shape. The 
remainder of the sac in front, on the outside and elsewhere, 
was formed by the integuments and degenerated muscular tissue, 
interspersed Avith pieces of bone. 

Some of the gentlemen who examined the limb seemed to 
think the disease might possibly have been an aneurismal tu- 
mor of the bone ; although the want of free arterial hemor- 
rhage, when it was opened, did not favor that idea. A careful 
microscopic examination, made afterwards by Dr. Ellis, threw 
a new light upon it, and seemed to verify the accuracy of the 
first diagnosis. The apparent coagula, being placed in focus, 
were found to consist almost entirely of myeloid structure, and 
the whitish -yellow substance interspersed with it, and which 
might easily have been taken for encephaloid matter, was found 
to be composed of fat globules. Mr. Paget, in his " Surgical 
Pathology," mentions an almost similarly deceptive case, in 
these words : — 

" None who examined this disease with the naked eye alone felt any 
doubt that it was an example of medullary cancer, with cysts abundant- 
ly formed in it. But, on minuter investigation, none but the elements 
which I shall presently describe as characteristic of the myeloid tumors 
could be found in it. These, cojDiously embedded in a dimly granular 
substance, appeared to form the substance of the cyst-walls, and of 
whatever solid material existed between them. The white, brain-like 
mass was apparently composed of similar elements, in an advanced 
fatty degeneration : neither in it, nor in any other part, could I find a 
semblance of cancer-cells." 

The patient recovered well ; and so far as I know, had no re- 
currence of the disease. 



Case CCCXI. — Encephaloid Tumor of the Head of the 
Right Tibia. JLmpiitation. — A boy, 16 years of age, of deli- 
cate complexion and light hair, was brought to me on Nov. 1, 
1859, by his father. He was suffering at the time from a large 



ENCEPHALOID TTOIOR. 525 

tumor, on the outside of the head of the tibia of the right leg, 
with an opening on its external part. The disease began five 
months before by a severe pain deep in the limb, which gradu- 
allv increased, and at the same time the bone enlarged at that 
point. About five weeks before, the tumor had acquired the 
size of a large apple ; and, the pain being very severe, they 
applied to a surgeon, who made a free incision into it, with 
partial relief for the time. 

When I saw him, the limb had become contracted and use- 
less : the pain was very severe, requiring the use of opiates, 
and his health was beginning to fail. I informed his parents 
that the only remedy was amputation, and that the disease was 
probably of a malignant character. The parents consented to 
the operation ; and the patient entered the Hospital, where the 
operation was done on Xov. 4th. 

After he was put under the influence of ether, I first made an 
incision into the tumor, in order to verify the diagnosis, which I 
found to be correct. The limb was therefore removed just above 
the knee. 

On making a section of the tumor, the greater portion of the 
bony calibre of the tibia was found destroyed, and its place 
occupied by a large encephaloid mass, interspersed everywhere 
with small o:ranules of bone, formino: a disease which, under 
the old nomenclature, would be designated as osteosarcoma. 

On the day following the operation, he was perfectly comfort- 
able ; and he made a rapid recovery. 

Case CCCXII. — Encephaloid Tumor commencing in the 
Popliteal Space. Amputation. Recovery. — A lady, 62 
years of age, requested me to see her, in consultation with her 
physician, in August, 1853. About three years previously, 
being then in good health, she perceived a small tumor in the 
popliteal space of the left leg. This, slowly increasing, pro- 
duced more or less pain, and embarrassment in the motions of 
the limb ; and finally, when I saw her, had attained enormous 
dimensions, extending up on the thigh, and nearly down to the 
ankle. The tumor was tense, elastic, and the surface of it covered 
with largely dilated veins. A certain amount of pulsation was 



526 TUMORS. 

observed in it, which at first led to the supposition that it was 
an aneurism ; but, on careful examination, and long-continued 
pressure on the femoral artery, which did not at all diminish 
its size, I felt confident that the pulsation arose from the con- 
finement of the tumor by the fascia over the popliteal artery, 
which communicated its impulse to it. The pain in it was 
excessive, and extended down the limb to the foot, and could 
be alleviated only by opiates, and was gradually wearing her 
out. 

The decision arrived at was, that the affection was maliofnant, 
and amputation of the thigh the only remedy. In view of the 
slight hope of recovery to be expected from removal of the limb, 
the patient was at first undecided what course to pursue ; but, at 
the end of a month, being nearly worn out by continued and 
increasing pain, she demanded the operation. This was per- 
formed on Sept. 24th. 

The limb being removed about half-way up the thigh, and at 
some distance beyond the tumor, it was found that the great 
vessels were matted together by inflammation ; and the artery, 
being separated and tied twice, broke through under the ligature, 
so that it was found necessary to plunge a needle, armed with a 
ligature, deeply into the muscles, and tie the artery, vein, and 
muscular substance in one mass. 

In spite of the unfavorable nature of the operation, the patient 
had a good recovery, though the ligature did not come away till 
after the lapse of eight months. On dissection of the tumor, 
after its removal, it was found to spring from the neighborhood 
of the tibia, which was more or less diseased, with bony pro- 
cesses projecting from it. The lower part of the femur, on which 
the tumor lay, was more or less eroded. The body of the tumor 
was composed of a lardaceous looking substance, interspersed 
wdth bony spiculse, in the centre of which was a cavity containing 
fibrinous clots, with walls resembling an aneurismal cavity. 
The popliteal artery was found in the back part of the tumor, 
while the nerves had been forcibly pressed from their natural 
position, and so dragged upon as to explain the torturing pains 
which had so much exhausted her. The tumor, being examined 
by Dr. J. B. S. Jackson, was by him pronounced malignant; 



CANCER OF FEMUR. 527 

and, being examined by Dr. Shaw with the microscope, he made 
the following report : — 

" Composed of well-marked cancer elements, and containing a large 
quantity of fat in the cancer-cells. In the portion of the tumor from 
Dr. Jackson, which I suppose to be the same, a similar structure was 
found containing an enormous quantity of fat, so as to obscure the 
view of the cells at first sight : this portion was whiter than that which 
you sent me." 

Remarks. — From the malignant character of the tumor, I 
had but little hope of the ultimate recovery of this patient, and 
was much surprised on a visit to Lynn, six years afterward, at 
being told she was in a state of perfect health. Though I had 
been constantly in her vicinity before, I had not inquired after 
her, taking it for granted that she had succumbed to the disease. 
On a visit to perform an operation, two months afterward, I 
took occasion to call upon her. I found her in good health 
and spirits, and greatly increased in weight, so as to be from 
seventy to eighty pounds heavier than at the time of the oper- 
ation. The stump I examined, and found in a perfectly healthy 
condition. 

The case is an instructive one, as showino^ a o-ood recovery 
and state of health at the end of six years, after an apparently 
desperate operation for the cure of a malignant disease. 

Case CCCXIII. — Malignant Tumor of the Condyles of 
the Femur. AmpiUatio7i. — A laborer, 35 years of age, en- 
tered the Hospital on March 1st, 1859, for a swelling of the 
knee-joint, which he stated had been of four months' duration. 
It first came on after a severe blow received by the slipping of 
a block of ice, which struck him on the lower part of the thigh. 
This confined him to the house for a few days, and he was then 
able to limp about till nearly the time of his entrance to the 
Hospital. Finally, he was obliged to relinquish walking, and 
confine himself to the bed, on account of lameness and excessive 
pain in the knee-joint. 

When he entered the Hospital, the whole knee-joint was oc- 
cupied by a hard tumor : the leg was slightly bent on the 



528 TUMORS. 

thigh, the lower end of the femur projecting a little forwards, 
as if displaced from its natural apposition with the tibia. Below, 
and on each side of the patella, was some elasticity ; above, it 
was quite hard. Various applications were made to the joint ; 
its motions were restrained by a splint ; and, finally, two deep 
issues were applied in its neighborhood, and the surfaces sprin- 
kled every night with half a grain of the sulphate of morphine. 
All these means did not have the slio-htest effect in mitio^atino^ 
the pain, and he expressed himself as unable to bear any further 
the excessive suffering from the disease. 

A consultation of the surgeons of the Hospital being called, as 
is usual in such cases before proceeding to extremities, the fol- 
lowing suggestions were made : That, from the excessive suf- 
ferino^, the disease mio'ht be an ulceration of the cartilaoes of the 
joint, or possibly it might be of a malignant character ; and that 
an incision should be made into the joint, and its condition ex- 
plored. If it proved to be an ulceration of the cartilage, that 
the ends of the bone should be removed ; otherwise, amputation 
of the limb should at once be performed. 

On being informed of the nature of the case, he agreed to 
have done what was thought proper. The following opera- 
tion was therefore done on Wednesday, March 30th ; preparation 
having been made beforehand of a splint, well moulded, to re- 
ceive the limb in case the joint should be excised. Being ether- 
ized in his bed, to save him from the pain likely to be caused 
by his removal to the operating room, he was carried up stairs. 
A firm pillow was placed under the joint, so as to support it 
in a bent position ; and an incision was made, commencing at 
the inner condyle of the femur, carried down with a semi- 
circular sweep over the tubercle of the tibia, and terminated 
opposite the outer condyle. The ligament of the patella was 
now cut through, and the joint partially exposed ; a great rush 
of fluid taking place as the capsule was opened. The' head 
of the tibia came into view in a perfectly healthy condition. The 
flap being raised, a most beautiful and highly colored tumor, 
covered with delicate synovial membrane, having large vessels 
running in every direction over its surface, very much distended, 
and formed by the lower end of the femur, was seen. The 



TUMOPw OF SARTORIUS MUSCLE. 529 

tumor extended quite up to the top of the synovial sac. There 
being no question as to its malignancy, the patient was immedi- 
ately slipped down upon the table, and his thigh amputated 
about the middle. More arteries required ligature than in ordi- 
nary cases of amputation from accident ; a fact which is fre- 
quently observed, when a limb has been amputated for malignant 
disease. The bleedino: havinf): been checked, and the surface 
being quite dry, the wound was brought together with two or 
three sutures ; and a compress, with bandage, carefully applied, 
to give the stump support. 

In the afternoon and evening, the stump became distended 
and painful, so that it was necessary to open the wound again, 
and apply one or two ligatures. It was formerly my habit at 
the Hospital, in order to avoid an occurrence like the present, 
to leave the wound open for five or six hours, and then have the 
dressino^ done after all oozinof of blood had ceased. My reason 
for relinquishing this practice was the excessive sensitiveness of 
patients for a few hours after operations, just as they recovered 
from the effects of ether, and their unwillingness to be interfered 
with. But where there is evidently much danger of bleeding, 
I consider the delay a lesser evil than the re-opening of the 
stump, searching for the bleeding vessels, and perhaps opening- 
fresh ones, while clearinof the wound from coao-ula, at the same 
time running the risk of subsequent suppuration, and sometimes 
of an ill-formed stump. 

The patient made a good recovery. 

Case CCCXIY. — Tumor connected icith the Sartorius 
Muscle^ secondary to Cancer of the Breast. Operation. En- 
trance of Air into the Vein. Hecovery. — This patient, 30 
years of age, had a tumor of the breast removed five years before. 
One of her sisters had also been subjected to an operation of the 
breast for an encephaloid tumor, and was well, and present at 
the operation. Another sister also had a tumor of the breast. 

The tumor in question appeared about a year and a half be- 
fore ; and, when I saw it, was four inches long and three inches 
wide, commencing just below Poupart's ligament, and extending 
down the thigh. 

67 



530 TUMORS. 

I was at first disinclined to advise any operation, fearing 
that this was a fresh demonstration of malignant disease. On 
further consideration, and having repeatedly examined the pa- 
tient, finding no aifection of the neighboring glands, or of 
abdominal disease, and she being very urgent to have an 
operation done, I finally consented to perform it. The tumor 
was found incorporated with the sartorius muscle, which was 
spread out on the back part of it. This being cut away above 
and below, the tumor was detached from its various adhesions. 
When it was lifted up, in order that the dissection might be 
prosecuted underneath it, on cutting the saphena vein where 
it pierces the fascia, a distinct sucking sound was heard, as of 
the air being pumped into the vein. The finger was immedi- 
ately placed over the mouth of the vein, and the farther admis- 
sion of air prevented. The pulse remained for some time quite 
weak, and the patient recovered very slowly from the ether, 
of which but little had been inhaled, and as readily as usual : 
whether this arose from the effect of the latter agent, or from 
the entrance of the air into the vein, cannot be readily deter- 
mined. The tumor, on being laid open and examined micro- 
scopically, displayed no malignant appearances ; and all the 
tissues in the neighborhood of it were in a healthy condition. 
I heard from her two or three years afterwards, and there was 
then no recurrence of the disease. 

Case CCCXV. — Tumor of Thigh, over Great Trochanter. 
A soldier, 45 years of age, at the battle of Fredericksburg, 
Dec. 13, 1862, was wounded by the fuse of a shell which burst 
over him, producing a compound comminuted fracture of the 
left parietal bone, followed by paralysis of the right leg. In 
four months, he recovered from the wound and its effects, so as 
to be at work. 

Four weeks after receiving the above wound, he noticed a 
small, hard, painless tumor on the right hip, on w^hich side he 
had lain during his convalesence. This continued to grow rap- 
idly, but did not interfere with the movements of the leg. 

March 19, 1866, he entered the Hospital. A hard tumor 
was found, about six inches in circumference, situated just 



FIBROUS TUMOR OF THIGH. 531 

behind the great trochanter of the right femur, with three dis- 
tinct nodules on its surface, attached to the sidn. It was 
slightly movable, and not attached to the bone. The integu- 
ment in the neighborhood was not affected. 

On March 21st, the tumor was removed, after careful dis- 
section, involving the fascia of the deep-seated muscles. On 
making a section of it, its walls were found to consist of dense 
fibrous tissue, which enclosed a firm, dirty, yellowish substance. 
There was no line of demarcation between the two. A micro- 
scopic examination proved it to be a simple, fibrous tumor, the 
greater portion of which had undergone fatty degeneration. 
This tumor was probably caused by long-continued pressure on 
the hip on tissues in a low state of innervation. 

The patient had a slow recovery, owing to the wound having 
been attacked by hospital gangrene, which was prevalent at the 
time. The wound not healing after some weeks, he was sent 
out of town ; ■ and I met him afterwards in the street quite well, 
and found that the large cavity left by the operation had at once 
commenced to heal rapidly on his removal from the air of the 
Hospital. 

Case CCCXYI. — Formidable Fibrous Tumor, situated 
deejoly in the Thigh. Operation. Recovery. — A gentle- 
man from Xew Brunswick, 32 years of age, consulted me on 
account of tumor of the thigh, in September, 1862. He had 
seen many surgeons, both at home and in Europe, about the 
tumor, and had been counselled by some not to have it inter- 
fered with. It was of eight years' standing, and had occurred in 
the following way : In the winter of 1859, while skating rapidly, 
his skate became caught in a crack in the ice, producing a violent 
wrench of the limb. The next day, the thigh became greatly 
swollen, and very painful. Four or five days afterwards, the 
swelling subsided, leaving, on the upper and inner side of the 
thigh, a lump the size of a small Qgg. This remained fixed ; 
and the pain, in a great measure, disappeared. He went on 
with his usual avocations until the spring of 1860, when the 
tumor began to enlarge, and since that time had slowly increased. 
Three months before I saw him, the tumor began to grow very 



532 TUMORS. 

rapidly; doubling in size, causing great pain, and preventing 
motion of the limb. 

On the upper and inner side of the thigh was a large, circum- 
scribed, movable tumor, situated deeply in the limb, under the 
extensor and adductor muscles and great vessels. It had an 
apparent pulsation in it ; but its diagnosis was obscured by its 
deep situation. 

The patient being etherized, the thigh was rotated outwards, 
and partly flexed on the abdomen. An incision, eight inches in 
length, was now made, over the middle of the tumor, through 
the skin. The fascia was then divided, which exposed the ad- 
ductor longus and gracilis muscles, spread over the tumor like a 
fan. The adductor lono^us beins^ cut throuoh the adductor 
magnus was exposed, which, being divided, brought the tumor 
into view, with its layers of cellular membrane. It was now 
laid bare, and gradually dissected or separated, with the knife 
and fingers, from its investments ; the hemorrhage being pro- 
fuse, mainly from large venous trunks, some of which had to 
be tied. An oozing of blood continuing, the interior of the 
wound was lightly touched with a solution of the perchloride of 
iron, and a sponge, enveloped in a linen cloth, temporarily 
introduced to fill up the large cavity and produce compression. 

The tumor was found to be fibrous. It was spherical in shape, 
about the size of a large cocoa-nut. It lay against the bone on 
its inner side, pressing the vessels outwards. Towards the latter 
part of the operation, the circulation became much depressed, 
and the face very sallow. Under the use of stimulants, in the 
course of a few hours the circulation was fully restored. In 
three or four days, there was considerable swelling in the thigh, 
which was relieved by a free suppuration. The wound, after 
this, healed well ; and, at the end of six weeks from the time 
of the operation, he returned home perfectly restored, in high 
spirits, taking his tumor with him. 

Case CCCXYII. — Uncommon Tumor of Thigh. Recov- 
ery. — A gentleman applied to me in January, 1866, for a 
tumor of the leg, which had appeared under the following cir- 
cumstances : About three months before, he was taken with a 



TUMOR OF THIGH. 533 

pain in his left knee ; the sensation being as if pebbles were 
in the joint. This was followed by an abscess under the skin 
over the joint. As he recovered from this, pain and swelling 
commenced about the middle of the thigh ; the pain being so 
severe as to require the daily use of morphine injections under 
the skin. It was supposed to be connected with the sciatic 
nerve. 

When he applied to me, he was pale and emaciated, and had 
lost about twenty pounds in weight. The knee was stiff, and he 
could limp only with difficulty. A hard swelling, as if on the 
bone, occupied nearly the entire thigh, and felt like ensheathing 
callus, such as is often felt, at the end of three or four weeks, 
around a broken femur. The whole swelling was A^ery sensitive 
to the touch ; but there was no redness nor appearance of a 
tendency to suppuration. It was difficult to say whether it was 
a tumor of the bone, the periosteum, or an inflammatory exu- 
dation among the muscles. The only case I had ever seen like 
it was a woman in the Hospital, March, 1862, whose case is 
Hven below. 

I advised rest, laudanum fomentations on spongio-piline at 
night, and a general tonic treatment. This plan was pursued 
for a week, and the superficial swelling subsided, leaving only 
the apparent hard tumor of the bone ; the pain being sufficiently 
alleviated to allow him to give up the opiate injections. On 
Jan. 28th, the rectus muscle suddenly disengaged itself from 
the swelling below, carrying with it a large, hard mass of lymph. 
Dr. S. Cabot, at this time, saw the patient with me, and agreed 
as to the treatment, but, with myself, was entirely doubtful as 
to the diagnosis. 

The patient persevered in the treatment, and consulted me 
once or twice afterwards, at the interval of a month or more ; 
and, when I last saw^ him, the tumor had almost entirely disap- 
peared. 

Case CCCXYIII. — Large Solid Swelling of the Thigh, 
lasting about two months, and then disappearing. — In 
March, 1862, I was called to see an unmarried woman, 26 
years of age, who, having about a week before received some 



534 TUMORS. 

check from exposure to cold, was taken with a pain in the upper 
part of the left thigh, followed by a deep-seated swelling, prin- 
cipally on the front and outer part, which ultimately became 
quite hard, involving about half the limb. I had her removed 
to the Hospital, and put under treatment. 

The tumor became more and more solid, the integument over 
it remainins^ natural. There was slis^ht fever, and the swellino: 
was moderately painful ; but no tenderness or swelling in the 
course of the great vessels of the limb. 

Several gentlemen who examined the tumor, at the end of 
three or four weeks, could make nothing of it, unless it was a 
rapid development of malignant disease. Under applications, 
principally of a warm and moist character, at the end of two 
months from the commencement of the disease the swelling 
entirely disappeared. 

Case CCQXIK.. — Erectile Tumor of Cheek. — On Jan. 
28, 1847, a man consulted me for a tumor, of ten years' stand- 
inof, in the substance of the risrht cheek, bearing' a strikino- resem- 
blance to a case already related. The right cheek was forced 
outward, and at times had been one-third larger than the left. 
With one finger applied to the inside of the cheek and the 
thumb to the outside, so as to embrace the whole substance 
placed between them, I distinguished a hard lobulated tumor, 
quite movable, situated below the zygomatic arch, and par- 
tially extending up under it. With a little force, it could be 
carried outward, so as to make a projection over the ramus of 
the lower jaw. During the examination, I felt something of a 
less resisting nature slip from under my fingers. After one or 
two trials, taking into consideration the history of the case, I 
came to the conclusion that I had to deal with a tumor per- 
vaded by erectile tissue. The patient entered the Hospital, and 
I operated on him in February. Before the operation, a number 
of gentlemen, who examined the tumor, could not be con- 
vinced that it was other than an ordinary steatoma. The pa- 
tient was fully etherized. The tumor was then made to project 
over the lower jaw, by forcing it from the inside of the cheek. 
The first incision laid bare the muscle. This being divided, a 



PAINrUL CUTANEOUS TUBEKCLE. 535 

mass of vessels, principally venous, projected through the 
wound. These, together with the body of the tumor, were 
dissected out, with some hemorrhage. The operation was ter- 
minated by embracing with a ligature the base of this congeries 
of vessels. A severe attack of inflammation followed, which 
terminated in an abscess in the cheek. He left the Hospital 
well, in a fortnight. The nucleus of the tumor was composed 
of a fatty substance, quite firm before removal, but easily broken 
up by the fingers after it was dissected out. The greater por- 
tion of it was made up of erectile tissue. 

Case CCCXX. — Painful Cutaneous Tubercle. — A wo- 
man, 30 years of age, had a small, projecting, nipple-shaped 
tumor on the skin of the right nates. It was of five years' 
standing ; and she complained greatly of the suffering occasioned 
by it, which was of the most insupportable kind, and occurred 
in paroxysms. At these periods, she would not allow any per- 
son to come near her. 

The wound was examined, after the excision of the tubercle, 
for the purpose of discovering if any nervous filament had been 
pressed upon by it; but none could be detected. Its texture 
was fibrous ; and no cancer-cells could be found in it, under 
the microscope. The character of the pain was the same as that 
observed in the subcutaneous painful tubercle. Entire relief 
followed its removal. 

The subjoined tables give the immediate result in one hun- 
dred and fifty-five cases of malignant disease, operated on by 
myself during a period of twenty-six years. The table, for 
the last thirteen years, consists only of Hospital cases ; and 
the whole table comprises only those patients who remained for 
a time under treatment ; many who submitted to minor opera- 
tions, such as cancer of the lip and of the integuments, leaving 
immediately after the operation, and no record of them being 
preserved. 

The cases up to 1852 were collected from the Hospital re- 
cords, by Dr. Albert A. Sawyer, and the remainder, by my son, 
Dr. J. C. Warren, foraierly house-surgeons at the Hospital. 



536 



TUMORS. 





5 
*? 


mall 

t'ear. 
of a 

from 


11 












1 


11 i 1 


II 


Hi! 1: 


e3 


i 






•a 


fc, a a) tH 




fill E 


-S 




•O 


1 




^ t^ .a i 

5 fl „ p t>. 


if 


>> 

1 


1 


5 

1 


5' 
1 

i 

1^ 


t> > a) 2^ a- = -g c« 
;3 c/^Mcg « ^ 




§ = " 1 

mil 1 1 


05 

|3 
































11 


_: 






% ^ £ 


• 






S 
























''';§ 1 ''1 


1 














ad o- 








c 








.2 o «4 








o 

•-S 

i 


1 ^ 




1 


411 1 -1^ 


1 


^ 




o 


1 ^ 




1 


g- a --n o g .2 

n o x X So, 


■^ 








W 




Pi 


w 










i oS . . . 




to 03 00 OT . OO ^ 











. <n 


-u . ja « 00 a> 




5555 £ „;5^ 






to . 2^ 




m ^ 


a 00 1: >- tH m 


t» 










^ ? 


5 e sa 03 cS c3 


;-. 


flSQQ ™ f-iQO 


t^ 


u 




O 






2 


oooo ? Sog 




>1 


liT) '*' "^CJ 




O^S 


r-( (N U3 (M Ol oi 


00 


OS-^iOCO C<j (MiCi-H 


rH 


rl 


InOrlScD 






12 '2 




-3 "2 




























|o '5 




'S 'o 




























15 M "S m 




"S CD "rt 








1 


3 


^ ^3 ^3 




^3 J 


f3 






J3 „ 


a "^ O.J 




a, ja a, 


^ 






> 




aj ^^p :: :.<o u :: 


- 


= - -s s — s 


t- 


" 






M 






^1 M 


1 














-6 






1 










fl 






^ 
















o 


a 








"Sb 






o 


o 

•J 


aj 


« ■« ^ 




1? 






■2 « . 


s 


P. 






illl i .s-i " 


.a 




Islll 






p^ 


! 


1 


» 


O'* 


^^Tt<^ -rl< tH rjl -^ ■* 


~^ 


CDCD'XJCD CO ^'^'S 


00 


00 


00 oooo 00 00 




•<*':t< 












1 


00 00 


CO OO CO OO 00 00 00 00 00 




ncoooooo 00 oooooo 








iHrH 


i-(T-lr-<i-l 1-1 rl rl rH i-l 


■"^ 




^ 


'^ 




d 


S^ 


00 <MCO CDiOOIMtH 


CO 


OJt^CDCO 00 00r-<CD 


00 


o 


O O (M O lO 


bo 

< 


O '*(M l~-*lOOCD 


(M 


co^Dioeo •* co-^-* 






CDiOrJ^Tt^eo 


E^S 


(iitafefe PLiEt;^^^"^ 


^ 


&;gpi^!ii fe ^pnp=; 


Ph 


Eh 


pti^jii^'p^; 


o 


rHCq 


CO-^lCCO t-COOJOrH 


C<l 


CC^lCCD t- CCC30 


^ 


(M 


CO •* un CD [- 


Iz; 










<M 


cq 


CNCOCJ(MiM 








^ 












i 


1 i 


.^ 




i 




1^ 




e3 ^ 


. . .1 ^^ . p - 


'S, 


r;;:;;: s ::?:; 


e3 


- 


^^'1^ = 




•G 


o -S 


o 




•c 




o 'G 




Cli 


a fk 


a 




CM 




B&3 



OPERATIONS FOR CANCER. 



537 






llll^ 






i;: 






















= 5 '-^ ^ .2 






Ci p 


-i S 


S "^ T'o a 








s = = £« 






£-5 


! i i 






a* S *i 


<=> •— ^ fc. 


•3 5 ■>< ." ^ 






g°l 


IIP 1 






5 S a 




maligna 
n axilla 
id in bo 
ear afte 
well t\ 






&2 ^-3 ^ 
2i * g a ^ 


lllil 


a 


s 


%1^'i 


iiril 


?, 


'-' 


§£g^.t^ = o^3^ 


S^lti 


5 


il 


i;-^ c<.D 


|2S£E.a 






^ 


s^cs ? 


o ^ w<: 



5 -s-^s?^?. 



^ 1 3 



C/5 




^ 


■s 


o 


•c 


t-H 


> 


<i 





u h a ^ C 

ci = C =! C 

Cq -^ -^ (M CI 



m *; ■" ? i; 

I 5 o ? ? 



iggS 



< Cvl ?« O W j^ ^J IM S T}i rt< 



CON s<i 



J= s c ■= ~ 



a. * t»cc 



53 cc 






3 .;2 X S - i 
SSo3 ::'i-J3 



-:£ O ^ -7 



a. to c3 

;2E ^ 



1151 



5 


1 


C5S5C5 ^ 
00 00 CO CO 


849 
849 
849 
84!) 
84!) 
849 
849 
849 
849 




fe fe « fe 'S 


fe-5 


1 


iiSI 


<j _r 




T-l 1— I-H r-( 




1— 1 r-1 — < 1— ( 


T— 1 T— 1 f-C I— 1 t-H 


I— ( •— 1 


"^ 


1— ( r-l 1— 1 <— 1 


— 1 n 


< 


- 




SS.ti^S^SS^ 


ssss 


s ^ss 


§s 


s 


S8SS 


S 


1 


s 


fe?is& 


Ss:?,f»iE=^s=i"^ss=i 


Cb^Eci ^ 


&^S!^=^S 


s^ 


ui 


feSs^g 


i>^ 


1 


s 


■MMCOCO 


CO T»< iC -^ 1^ -»- 55 O -< 

OJCCCCCCCCCCCOrPTji 


wco-^io 


^^^5S 


II^o 


s 


SSSLo 


s 



68 



538 



TUMORS. 



^ o 



:— -^ a ^ 



a; n 



> u 
o o 
S i>?i 

2^ I' i5 



is 



•Jc 









s £• 
o c 






s:« ^ - a 



? ■t; M • " - c-i . 



CO — OC 00 
■r-l X rl 1-1 



irsC. 



;5C::« P 






^ £ o o n 

« 4) o: = -E 

c S c ct ^ 

~ +J 'S TS 

« O ri . ^ 



5«§ 



£ c > 

— = 2 






C-2~TJ 



-O -3 



C -3 O 
c- i o 

A^ .^ -^ 






^.^ 






:: :; r :; o 



(MCO 



c o 



K ♦J w « ce cc 
J; C C C ;: S3 



Mi . . . oc oa . . 

*; • IX K 00 fc< t- a: 'I. 

OcieieS eS« aicic: 

O ^ •"• ^ ^'-.M -», '^ ^ 



42 — 



s P ^ 



SS « rt 

0, "^ iT 



Koi W t» W ;i. 












2-^ • 









I coco «^ • CO oc ^ 

_, _i_(_-i^H -Hf— 1-1— 1-Ji— I (M~.ir<i'vi rvi'-- ^^t>.'- '^ 

! lo io lo Li lO o o .c ic Lo o ico o >b to o o !? - Q, 5" S" ^ S ^ ce' ri ? I: S 

ooooo) ooccoooo ooooooxocj-j ccGcccoo oo^^r^ »§« ^Pj:;.^^;^ >53 

1 f-H rH T-1 r— 1 1-1 r-1 i— t t~^ »-^ ^1 rH 1^ rH r^ f~H r1 r-l t-h ^^^fi^ ^»e5 ^ f^ ^^ ^, ^, f^ r^ "^ 



r. 

<; 


coTjiCO 


ocoiooo 


c^ i-o «r3 CO ic '^ 


g^S^g 


SSS^ 


ss 


s^^^^s 


^^ 






w 


s:»-s 


E^f&fa^g 


^5E,Eaa^fi,2 


SS^^ 


g'*SS 


fag 


SSSfeSS 


fafa 





SS3 


SSS8 


!§i5§§S[= 


f-l?2,tt2 


cc t^ooos 


6000 


SS^^SS 


§8^ 



£ 1) 



OPERATIOXS FOR CAXXER. 



539 



C.5 

C "S 



^t23 




g 


S >=; = 




? 






® . 


c-=-g3 




"x a 


§5*^ 




j: 2 


•J c j: .-S 




.X tc 


s. s:.= ^ 




-= 2 


o — '■ ~ 




5^ S. 


= 3-= i) 


5 


2^ 


i 


"r=S^ 


■5"= = ii 




= - = 


§ «-^ 


SJ 











t: = ^ .5 — -^ — . 



111 tl 




go 




ease a re 

and not 
tient died 


•pt. 14th ; r 
before opc 
lile nur.siii 
ancer; ope 

volved wh( 
; internal 


liljl 




,3 J 




5 t^ 




r3 3 




don again S 
nary tumor 
appeared wl 
ated with e 
xive pain, 
lit tumor in 
into throat 


perat 

iced 

veil 8 

well 

remo 

with 


? 


55 

-- 


s 

a. 


11, 18 
d to t 
rodei 
open 


iiilll 


5 


i ^ 


1 


OW W( 

tende 
ise of 
third 


perate 
ma mi 

umor 
infilti 
exceK 

ecurrt 

jected 
tied. 


^ — G X 




s 


sc 


■z 


Or- - 






o o ;: 

c ; 3 
O ! 3 



••= s 



3 = S = S 



ioi-?«t- !-i cceoii eo ocom r-i 



s s = 

00 O .-H 



1 i 



.2-0 






S :3 a.:S 

<1 s<;s 



OSS 
t. >> >. CSC *i 



1 


fig 


gs 


g 


^ 


t2-SS 


eo 


Sf2S 


(M 


s;^53 


§ 


CO 


2 


s 


S5 


X 


N- 


S'-^ 


S::^ 


Eel 


^SS'^ 


s 


s.':^s 


s 


==:s==; 


s 


&; 


EeI 


b 


S 


^. 


iS- 


§§ 


S 


§ 


gj^gg? 


g 


lis 





ll§ 


1 


i 





s 


(M 



540 



TUMORS. 



,a to 

Hi 

a «« >; 
1*5 ■ 



1% 



^ to 
.2 1 

u aT 



S 5 S' 



i'^TS'S 



O .O g -fi P^f^ 



■ So 



1 

SS-ag d 



^1 

7; o 

53 e3 



1 <t J n 

-« S-t^ 2 

•;:; c ^ es 

a M ^ ii 



ai ■' rt a 



S-d 



« =* w 

5 => 

., 4J.3 



C " !- — T3 



0-0 


TS 


£ 


II 






















c 
.2 




53 

s 


s 

fcX) 


Is 


S3 
1 


a 

Si 

3 
0" 


6 


-a 


g 


., 


<1 


0. 


i 


,Q 










^ 


3 




'5 




1 


4) 


_>. 


c 
s 




a; 




"2 S 



0/ a) 

t> . > 

a> — o -H 

1 II I 



o 



;ii o 

fcog 



.WIS 



a|.l 



£5 fl 
g 9 o 



-# Ttl « «? 1-H CO 



coioc^ 



«j » a> 











ri 






TS 








-a 




^ 




1 


3 

.3 




' a, ja 


^i 




3 — "3 




li 


"5 





111 









^ 




a> 


'cj 


"S H a. 






a, 


a 


'Z ^ ^ 




w 


s 


W VI 


S 


c/iS 


mVH 





c»^ 


H 


W 


t5iS3 










^ 








>4 

















^ 






^ 


2.2 


3 






.2 


a 


3 


a3 


d 


1 
^ 






lis 


■^ -d -^ ,^ 


'a 
a 


aj 

3 . 






if. 

<j 






y 




S2 


to 


oj 3 


.^.^.ip 


-Is 


9f 


& 


.. M 


•^g 




&1 





M 


K 


hJ&HO, 


P5«i:z 


Z, 


Hiz; 


J 


f5 


hjM 


1 




CO 

i-H 


02 
CM 


June 22 
Oct. 18 
Nov. 6 
Dec. 3 
Dec. 26 
Feb. 20 




June 19 
Ang 12. 
May 18 
Sept. 28 






p ^ i^ 

rt « eS 


« p. :3 

S<2 






































--11M 


' 'MM 


PP#P 


Tf"** 


^^o 


10 


gJ8 






p 


P 


5P 


^tp'p'p^-p 


'P^P 


CO CD 






PS-'P 


















C»0 


tHCO 


s 


-0 


JS;?:^ 


<i! 


5 


C-l 


CO 


lO uO 1< -* -* l- 


:OrHTH 












CO 


3 


?^ 


&^ 


&; ii g i] &; 5;^ 


E^Sg 


S==is^ 


S^ 


S3 


^^2 


f^'sa 


6 


CO 


'^ 


lO 


CD I- 00 3i -^ 


2^1 ?5^ 




g5^ 


s?? 


oi^^ 


gis^ 




T-l 


"-H 


■-1 




-I'-' 








""""* 


'"' 


-T-l 


1-1 t-l rH 




"3 
1 


























"" 


■~ 


'"'"'" 


•" " 


'"•"'" 


'"'"''" 


" " 


" " 




































'"' 

























OPERATIONS FOR CANCER. 



b'il 



as 



"3 — 

^ a 



c a 









^ 



?;a 



cc S 



S5 1 



o '^•oo -^. " o "^-^.o "^ >> >> ^ a 



o .,-. 









-£ 2.S-3 

'rH — — > 



_2 O. , g Q, 








w.o^;53 


i::-^='?2;2; 


„ocoo 


^ 


5 


1 


May 
June 
June 
Nov. 
Mar. 


Mar. 
Mar. 
May 
May 
May 


May 
June 
.June 
June 


a 
3 
-5 




8 


§!?iSS§ 


^W§'§>3 


^ff3 


§ 



< 


00 


ScSSSg 


t^ iC ■# 
T*. ra CO I- 1- 


^^SS 


1.-3 


1 


! 










^' 


j;;s-5=-SiS^ 


S S ^ S '* 


sss^ 


S 


Z 


1 


§:;g^^ 


to CC Ij CO 


J2r??^3 


2 




r-l P-IT-I.-I 


i-Hi-lr-irH 



CHAPTER XII. 
GUNSHOT WOUNDS. 

Since the late war, gunshot wounds, and other wounds pro- 
duced by warlike weapons, have received an increased interest, 
and are now being extensively illustrated by the elaborate works 
published by Surgeon-General Barnes, under the direction of 
the American Government. Some of the beautiful photographic 
illustrations of important surgical cases and operations, by Dr. 
George A. Otis, Surgeon U.S. Volunteers, and Curator of the 
Army Medical Museum, which surpass in the art any thing of 
the kind which has thus far been accomplished, have already 
appeared. Circular No. 6 — being the preliminary surgical 
report of Dr. Otis to tlie Surgeon-General — is of especial 
value. The same may be said of the medical report by Dr. J. 
J. AVoodward. " The battle-field lists of wounded, for the years 
1864-5, include over 114,000 names." 

To give an idea of the amount of material which presents 
itself for observation, I make the following quotation from Dr. 
Otis's valuable report : — 

" In comparing the numbers of cases of some important injury, as, 
for example, gunshot fractures of the femur, it is found, that, in the 
French Crimean army, there were 459 such injuries, and, in the Eng- 
lish arm)^, 194 ; while over 5,000 such cases have been reported to 
this office. Or, if one of the major operations is selected for com- 
parison, as excision of the head of the humerus, the Crimean returns 
give 16 of these excisions in the British, and 38 in the French army ; 
but the registers of this office contain the detailed histories of 575 
such operations." 

The Crimean war gave rise to one or two valuable works, 
bringing the subject more particularly before the public than it 



WOUND OF HEAD. 543 

had been since the splendid work of Larrey, and those of Gu- 
thrie, Hennen, and others during the wars of Napoleon. 

In regard to the destruction of life, caused by the passage of 
projectiles from fire-arms near the body without touching it, 
there has long existed a popular delusion. In many cases, it has 
been proved by dissection, that the body has been struck by the 
ball, which left no external marks of its passage. Large effu- 
sions of blood have been found in the thoracic and abdominal 
cavities, organs ruptured, and bones and muscles disorganized, 
without any abrasion of the integument outside, to indicate 
the point where the missile struck. This is the result of the 
elasticity of the skin, which in itself offers but little resistance, 
yielding to a great degree, while the firmer texture of the bones, 
muscles, and organs, does not permit of so much relaxation. It 
may fairly be said that no one was ever killed by the wind of a 
cannon-ball. 

These remarks are confirmed by conversations with military 
and naval surgeons who have had the experience of the whole 
war, and who have had an opportunity of witnessing and learn- 
ing, by personal experience, the effect of the passage, near the 
body, of projectiles of a larger size than any ever used in war- 
fare before. The testimony of officers and soldiers is to the 
same effect. 

In the early part of the why, before the subject had received 
much attention in this country, I published some cases of gun- 
shot w^ounds, also of injuries of the nerves from w^eapons ; the 
results of treatment of the latter, at that time, being very 
meagre. A few of the former cases, with additional ones, are 
here presented. The latter have already been given. 

Case CCCXXI. — Bullet sjjlit by coming hi Contact with 
Bone. — An occurrence very common with the ordinary spheri- 
cal bullet is to split on coming in contact with bone. The fol- 
lowing case occurred at the battle of Bull Kun : Lieutenant 
B. was struck on the left side of the os frontis with a round 
ball, and was supposed by his comrades to be mortally 
wounded. He w^as made prisoner, and taken to Richmond. A 
projection was felt under the scalp, about four inches from the 



544 GUNSHOT WOUNDS. 

wound in the integuments, and ian incision made over it, from 
which half of the bullet, with a highly polished cut surface, was 
removed. He remained seven months a prisoner at Richmond, 
during which time the wound in his forehead continued open, 
and suppurated freely. He was troubled with some uneasiness 
in the head, and occasional headache. On his arrival at Fortress 
Monroe, after his release, this discharge still continuing, he 
was examined by Dr. Cuyler, United- States Army, who dis- 
covered a metallic substance deep in the wound. This was 
skilfully extracted. The patient states a small portion of brain 
escaped at the time. On examination, the extracted body 
proved to be the other half of the ball, flattened on both sides, 
and having embedded in it a portion of tlie skull. On the next 
day, a piece of the inner table of the skull, which had been 
driven before the ball into the brain, was also extracted. After 
the removal of these substances, the wound healed. 

The patient afterwards came under my care, and remained 
for some time in delicate health. 

Dr. Fox, of the Naval Hospital at Chelsea, showed me a case 
in which a ball penetrated in the middle of the arm, and was 
cut out over the scapula. In its passage, it struck the edge of 
the scapula; the ball being cut nearly in halves, and flattened 
out in this position. 

In almost every instance I have met with, when the round 
ball encountered bone, it was either flattened, or, if it met the 
edge of a bone, as of the jaw or rib, it was split. 

Case CCCXXII. — Gunshot Woimd in the NecTc. — At the 
battle of Bull Hun, a man was struck in the neck, just behind 
the angle of the jaw, over the point of bifurcation of the carotid 
artery. The shot being fired from below, the ball penetrated in 
an upward direction, and struck the edge of the jaw, which cut 
it in two, one portion remaining in the neck. The other, and 
larger part, passed through the base of the tongue, carried 
away a portion of the alveolar process of the upper jaw, and 
escaped through the cheek. The hemorrhage from the w^ound 
was at first rather profuse, but was checked by pressure with a 
handkerchief, and did not recur. The wounds healed kindly ; 



WOUND OF OS CALCIS. 545 

but an abscess formed in the neck, which was opened, and por- 
tions of lead and spicula of bone were removed from it. After 
one or two abscesses of this kind had formed, he recovered. 

Case CCCXXIII. — Gunshot Wound in the Leg. — A man, 
27 years of age, was hit by a bullet on the inside of the left leg, 
about its middle. The ball passed through the tibia, producing 
a compound fracture of the bone. The fracture united after a 
very long time, as also the wound of entrance. The wound of 
exit, however, remained open, and when I saw him, eight months 
after the receipt of the injury, was of the size of a half-dollar, 
and had an unhealthy look, resembling epithelial cancer. The 
edges of the wound had already been dissected up, in the hope 
of relieving tension, and producing a healthy state of the wound. 
I determined to dissect out the entire ulcer, which was done. 
In the centre of the wound, and between the bones, a black sub- 
stance was discovered in an encysted state. This was at first 
thought to be powder, but was afterwards explained by the pa- 
tient stating, that when in Richmond, on account of a sloughy 
condition of the wound, he had been in the habit of sprinkling 
it with charcoal, some of the granules of which had been covered 
up, and retained there. The wound, after the operation, took 
on a healthy action, and soon closed. 

Case CCCXXIV. — Gunshot Wound through the Os Cal- 
cis. — The following case exemplifies the very slow way in which 
wounds of a spongy bone take on the healing process : Richard 
Roe, a private in the First Regiment Massachusetts Volunteers, 
was struck by a ball in the left heel ; the ball passing round the 
OS calcis, and coming out on the oth'er side. The enemy were 
firing up from a hill, a little below. Shortly afterwards, he ex- 
posed the other foot, when another ball struck him in exactly 
the same spot on that foot, passing through the os calcis. He 
Avas carried a prisoner to Richmond, where he was under the 
care of Dr. Charles Bell Gibson, of the Confederate Army. In- 
flammation was so extensive, and the pain so severe, that he at 
one time requested Dr. Gibson to amputate the foot, Avhich he 
very properly declined to do. The patient came under my care 

69 



546 GUNSHOT WOUNDS. 

about six months afterwards, having regained his liberty. On 
probing the wound, I discovered a large piece of detached bone. 
The wound was enlarged, and a portion of bone, the size of a 
chestnut, removed ; and the bone, which was rough in one place, 
made smooth. After this, the wound gradually healed, so that, 
at one time, he could use his foot in walking. It then became 
inflamed again, and began to discharge. I advised him to enter 
the Hospital, two months after the first operation. The bone 
was then exposed by a large incision, and the whole interior of 
the cavity excavated with a chisel and drill. The mouth of the 
aperture in the bone was made much wider than the interior. 
In April, 1862, nearly nine months after the accident, the 
wound was nearly healed, but still painful if he attempted to 
walk ; and it was difficult to say whether he would recover with- 
out the removal of the whole bone. The rest of the foot was in 
a perfectly healthy state. In June, 1862, the wound had con- 
tracted to a small point, there was a serous exudation from it, 
and he was able to walk about. Now, 1867, it is perfectly well. 
In most cases where I have had to operate for caries of the 
OS calcis, repeated operations have been required. 

Case CCCXXV. — Gunshot Wound in the Thigh. JSfo 
Trace of the Ball at first to be discovered. — Major S., while 
at the head of his regiment at the battle of Newbern, received a 
ball in the upper and front part of the thigh, about two inches 
below Poupart's ligament. The whole regiment, at the time, 
were in the advance, and were exposed in an open field, in a 
reclining position, firing on the enemy, who, in return, were 
firing down upon them from breastworks. He felt a blow on 
the leg as if from a stone, and was not aware that he was 
wounded, until, on removing his coat, he saw the blood flowing 
freely. He went on giving his orders until he became faint, and 
was taken to the rear. The wound, being probed by the sur- 
geon, was found to extend in a direction downward and inward 
for three or four inches. The ball could not be found in the 
wound, nor could any trace of it be detected elsewhere. The 
only sensation he felt, in addition to a general want of power in 
the limb, was that of slight numbness in the calf of the leg, and 



WOUND OF THIGH. 547 

a soreness in the foot. Perfect rest of the limb was enjoined 
upon him ; and, shortly afterward, he was brouii:ht home in a 
transport vessel, with other wounded soldiers. I saw him, in 
company with his physician. Dr. Charles Gordon, about three 
weeks after the date of the injury. An excavated ulcer, of the 
size of a quarter of a dollar, marked the situation of the entrance 
of the ball. Underneath it, in the cellular membrane, was a 
deposit of lymph, which, on being moved to and fro over the 
muscles, gave at first the sensation of the presence of a ball at 
that spot. A small pinhole in the centre, from which issued a 
serous iluid, at first seemed to confirm this view : the history of 
the wound, however, was opposed to it. A probe, being gently 
pressed into the opening, encountered no foreign substance. The 
patient being of fine physical development, and quite free from 
fat, the contour of the various muscles was strongly marked. A 
careful examination was now made of the whole limb, com- 
mencing at the toes and going up to the groin, making such 
manipulations as to leave no one of the muscles or intermuscular 
spaces unexplored. Not the slightest pain could be produced, 
or induration felt, to mark the presence of the concealed bullet. 
Finding no trace of the ball, it was decided to allow the patient 
to use the limb. On first making an attempt to stand, he found 
much difficulty in doing so, both from the stiffness of the wound 
and from the disuse of the limb ; but, being supported by two 
persons, and making an eflfort, he was gradually enabled to 
move around the room. I advised a continuance of this exer- 
cise, in order that he might regain, as soon as possible, the power 
of the muscles , and with the hope that the muscular action would 
bring the ball from its hiding-place. This proved to be the 
case ; for, in about a couple of weeks, a hard, movable sub- 
stance, which felt like half a sphere, was found travelling up 
the limb. The bullet, it was hoped, would follow up the track 
of the wound ; but it was soon discovered that it was very mova- 
ble, quite under the rectus muscle, and could not be distinguished 
at all when this muscle was contracted. After arriving under 
the old wound, it was thought possible that it might rest there ; 
but it was found that its disposition was upwards, towards the 
groin. Major S., being very desirous to get rid of it, and re- 
join his regiment, decided to have it removed. 



548 GUNSHOT WOUNDS. 

The ether being given, the patient was placed on a table, with 
the light from above ; and an incision was made through the 
skin, cellular membrane, and fascia, and the muscle uncovered. 
No cicatrix could be found further, as a guide. The ball was 
now fixed by an aid, and the muscle carefully cut through ; a 
vessel that ran across it being tied, so as to prevent any deep- 
seated effusion of blood. The ball, from its constant disposition 
to change its position for an inch or more, caused some embar- 
rassment. It was felt to be resting on the bone, and was then 
fixed by two fingers in the deep wound, and the muscular fibres 
over it cut, and its blue color was seen through the delicate in- 
vesting sac. It was necessary to divide this in several directions, 
before it could be pushed out with a director. It was a round 
bullet, flattened on one side, as if it had struck the bone, and 
then glanced down the limb. The bone, not denuded, could be 
felt beneath. The wound was brought together by adhesive 
straps, and a cold water-dressing placed over it. The most 
rigid quiet was enjoined. The limb, on the following day, was 
8ore and swollen ; and, on the fourth day, an abscess formed in 
the situation of the sac which contained the bullet, and dis- 
charged itself through the wound. By continued rest of the 
limb, and absence of muscular motion, any effusion of pus under 
the muscle was prevented. The patient completely recovered. 

In the present instance, and in one or two similar ones, no 
tenderness in the track of the ball pointed out the course which 
it had taken ; and this fact is important, as the want of sensi- 
bility in the track taken by it is occasionally given as an. argu- 
ment that it has not entered at all. As before stated, a pain 
was felt in the calf of the leg, at the time the wound was re- 
ceived ; also a numbness of the foot, and soreness about the 
ankle. The former disappeared after a time ; but the soreness 
of the ankle continued until the extraction of the ball. 

Case CCCXXVI. — Gunshot Wound from a Conical Bul- 
let in the Calf of the Leg. — Lieutenant C. , of the Second Mas- 
sachusetts, whose regiment had fought during the whole day, 
as rear-guard in retreat, the day before the battle at Winchester, 
and probably saved the army, arrived in camp at twelve o'clock 



WOUND OF LEG. 549 

at night, having marched thirty-five miles without food and 
drink, except the muddy water of the roadside. Lieutenant C. 
had charge of the camp-guard for the night. At four o'clock 
in the morning, the battle began, and lasted four hours ; and, 
when the regiment was in danger of being surrounded, the order 
for retreat was given. The regiment formed, and marched 
down the hill into Winchester, regardless of the enemy in full 
pursuit, who were firing into them. Lieutenant C. was in com- 
mand of the rear company ; in fact, the last person bringing 
up the rear. He received at this time a shot in the calf of the 
]eg, the sensation being that of a violent blow with a club, which 
knocked him down. He attempted to rise, but, after stumbling 
a few steps, fell headlong. By this time, fortunately, the ser- 
geant of his company perceived his situation, and, being a man 
of great size and strength, took him in his arms, carried him 
about two hundred yards into the streets of Winchester, and 
deposited him in the only ambulance-wagon that happened to 
be there. A number of other wounded men were put into the 
same wagon, some of them lying upon him. He contrived to 
put his head out of the front of the vehicle, so as to get air ; and, 
in this position, with a man lying on his wounded leg, remained 
until they arrived in Williamsport, on the following morning, 
— some twenty hours. He was so completely pinned to the 
spot, that he was unable to sheathe his sword, which lay drawn 
by his side, just as he was placed with it in the ambulance. 

On the passage through Winchester, a shell, apparently 
thrown at the ambulance, which, if it had penetrated, would 
have destroyed all the wounded within, killed a man lying within 
two feet of Lieutenant C On the afternoon of the following' 
day, Lieutenant C. had his wound examined. It was found 
that the ball had penetrated at the outer and upper part of the 
left leg, passing through the belly of the gastrocnemius muscle, 
in the vicinity of the great vessels, and had been stopped by 
the bone. It had carried in with it a patch of the trousers 
and the drawers, which were of thick knit woollen, without 
tearing them. From the swelling of the wound, the whole of 
this plug, nearly as large as the cork of a quart bottle, had 
been completely wedged into it, so as only to be withdrawn by 



550 GUNSHOT WOUNDS. 

free incisions. The wound remained quite painful for a few 
days, until suppuration had commenced ; and, after the lapse of 
a month, slowly healed, the patient getting about on crutches. 
The leg was somewhat bent, and could not easily be placed on 
the floor, on account of the contraction of the injured muscle. 

The case is given somewhat in detail, to show to what extent 
the soldier is exposed, independently of the danger from his 
wounds. That a young man, scarcely eighteen, should be able 
to march thirty-five miles with his regiment, constantly fighting, 
and without food, keep guard all night, engage in a battle 
lasting four hours the next morning, be wounded, and, while 
suffering and bleeding, lie twenty hours with a man on his swol- 
len limb, with nothing to sustain him, except on the second day 
a swallow of whiskey, — shows how much the human frame will 
bear when assisted by spirit and determination. 

This patient was afterwards wounded in the arm, injuring the 
nerve ; and the case is related in the chapter on injuries of the 
nerves. Subsequently, he was twice under my care with serious 
gunshot wounds. It is a curious fact, that, before the war, I 
had him in charge three times, with fracture of the leg or arm, 
being an uncommon instance of repeated injuries requiring sur- 
gical assistance. He finally fell a victim to the results of expo- 
sure, incurred during Sherman's campaign. 

Case CCCXXVII. — Wound in Chest from Grape-shot. — 
A soldier, 28 years of age, was brought into the Hospital on ac- 
count of a wound in the thorax, received a week before at. the 
battle of Newbern. The ball, which was an iron one, weighing 
six and a half ounces, struck him, as he was in a stooping posi- 
tion, in the left axilla, wounding the fleshy part of the arm, 
which was in contact with the side. It forced in the ribs, prob- 
ably ran between the skin and the parietes of the thorax, 
and made its appearance under the skin of the sternum, where 
it was cut out. The ribs were broken at their junction with 
the sternum ; the lungs wounded, and he expectorated blood. 
In what manner the wound in the lungs was produced, it was 
impossible to say, — whether by the ball or the fractured ribs. 
When he entered the Hospital, no tenderness or local appear- 



WOUND OF PELVIS. 551 

ance indicated the track of the ball ; so that it could not be 
said whether it had gone through the chest, or had run along 
on the outside of the ribs. The wound in the axilla healed 
rapidly, but on the sternum very slowly. There was no fis- 
tulous opening left, and no discharge of bone. The patient 
recovered slowly, his principal symptom being great debility. 

Case CCCXXYIII. — Bullet in Pelvis. Excruciating 
Pain in Sciatic Nerve. Operation. Relief. — J. Y., aged 
18, received two balls at the battle of Williamsburg. One struck 
him on the upper and back part of the left arm, and went behind 
the bone, coming out in front of the chest. The other entered an 
inch above a line drawn midway between the trochanter major 
and middle of the sacrum, in the left hip, and disappeared 
there. He was disabled, though not in great pain at first. A 
week after, he was seized with the most excruciating pain in the 
course of the sciatic nerve of that side. He was taken to Balti- 
more, from which place he was brought on to Boston by steam- 
boat and railroad, being carried always in his father's arms, 
to lessen the jar from the motion of travel. I saw him about 
ten days after the receipt of the wound. His left limb was 
drawn up, and he could not make the slightest movement with- 
out severe pain. A probe, passed into the wound, penetrated 
three inches, when a hard substance was encountered. Whether 
it was bone, or the bullet crushed against the bone, could not be 
determined. 

The following day, I had him removed the Hospital, and 
made an exploratory examination under ether. The external 
wound being enlarged, the finger passed through the gluteus 
maximus, under which was a cavity. Still farther on, through 
a narrow space, the pelvis was reached, and a smooth opening 
w^hich appeared to be the sciatic notch. On the inner side of 
the notch was a hole, through which the ball had penetrated into 
the pelvis ; the spicula of bone lying loose in the neighborhood 
of the sciatic nerve. These were removed. Another smooth 
cavity, which would hold an ounce of fluid, had been formed 
under the deep muscles. A probe passed easily two-thirds 
through the pelvic cavity, without encountering the ball. Water- 



552 GUNSHOT WOUNDS. 

dressings, and a poultice afterwards, were put on the wound; 
and the patient was much reheved by the operation. The prin- 
cipal cause of irritation appeared to be the fragments of bone 
lying on the great nerve. The situation of the ball does not 
appear. The patient returned home greatly relieved ; and, so 
far as I have learned, the ball never made its appearance, nor 
caused him farther trouble. 

Case CCCXXIX. — Molar Tooth lodged in the Tongue. 
— A soldier, about 20 years of age, entered the Hospital, about 
ten days after the battle of Williamsburg, having received a 
wound from a bullet, whicli struck the right side of the lower 
jaw, and passed out through the upper lip. The jaw was shat- 
tered ; and, when he entered the Hospital, there were purulent 
deposits connecting with the neck externally, and the mouth 
internally. The patient was etherized ; and, the wound being 
explored, pieces of bone were found everywhere buried in the 
substance of the cheek and the surrounding soft parts. These 
were extracted, and the wound healed rapidly. Some weeks 
afterward, he presented himself at the Hospital, with a swelling 
in the tongue, the edge of which had been wounded by the bul- 
let, and which, until lately, he had been unable to protrude. 
On examination, a hard body was found embedded in the sub- 
stance of the organ, which, on being cut upon, proved to be a 
molar tooth, which had been knocked out of the jaw, and buried 
in the tongue. 

Case CCCXXX. — Bullet lodged in the Corpus Oaver- 
nosum. — I was invited by the late Dr. Fox, Surgeon of the 
United-States Xaval Hospital at Chelsea, to see the following in- 
teresting case and operation : On 30th May, 1862, a man about 
30 years of age, while engaged in a boat attack in Florida, was 
fired upon by a party from shore. One bullet passed through 
the left leg near the calf, and was cut out on the opposite side. 
Another struck him at the outer and upper part of the same 
limb, passed through the thigh, emerging near the root of the 
scrotum in the fold of the thigh. It then entered again, near 
the same spot, and disappeared, and he had no farther trouble 



WOUND OF VERTEBRAL ARTERY. 553 

from it for the time. He retm'iied home, and came under the 
charge of Dr. Fox. Afterwards, the ball was discovered at the 
root of the penis, in the corpus cavernosum of the left side, from 
which place it gradually worked over to the right. The man had 
no difficulty in urinating, and no pain during erection. The point 
of the bullet, which was a ^Slinie one, was towards the body. 
It was firmly held by the fingers, and then cut down upon. The 
skin w^as first divided, then the strong fibrous covering of the 
cavernous body : and, although the incision was quite free, 
the foreign substance resisted the use of ordinary forceps, the 
elastic force and suction of some of the tissues operating to pre- 
vent its extraction. The wound being held well open, a pair 
of bullet forceps was introduced, and the ball slowly extracted, 
as if from a bed of India-rubber. There was no violent rush of 
blood from the erectile tissue, but a slow-continued discharge 
as from a large vein. This w^as controlled by means of a sponge 
and bandage. A gradual suppuration, with apparent elimi- 
nation of the sac, which had formed around or been pushed 
before the foreign body, followed ; and the patient recovered 
in the most satisfactory manner. The case is important from 
its rarity, and for the practical facts which it teaches in regard to 
the danger from interference w4th the erectile tissue, which at 
first would appear likely to be more considerable. 

Case CCCXXXI. — Gunshot Wound, cutting off the 
Vertebral Artery. — Cornelius Mahoney, 11 years of age, was 
brought into the Hospital on the 25th of May, 1861, having 
received the charge of a pistol, loaded with stones, accidentally 
fired by a companion. One of the stones grazed his forehead, a 
second struck him on the cheek, and a third penetrated the neck, 
about half an inch below the mastoid process of the temporal 
bone. He received the charge while in a stooping posture, and 
was taken up bleeding profusely. When brought into the Hos- 
pital, the bleeding was nearly checked ; water-dressings were 
applied, and the patient kept very quiet. I saw him on the fol- 
lowing morning ; and, as there was a disposition to hemorrhage, 
he was etherized, with the object of removing the foreign body, 
if there was one, and checking the bleeding. A finger passed 

70 



554 GUNSHOT WOUNDS. 

into the wound penetrated deeply into the neck, and finally en- 
countered what at first appeared to be a mass of gravel ; a por- 
tion, however, being removed with the forceps, showed it to 
be bone, and what afterwards proved to be the transverse pro- 
cess of the second or third cervical vertebra. The hemorrhage 
now returned violently, and but little doubt existed that the 
vertebral artery had been cut off. A systematic plugging with 
small bits of sponge was made, and the bleeding checked. On 
questioning the father of the boy, it was ascertained, that, while 
they were engaged in arresting the bleeding at his house, with 
a handkerchief, a small pebble was discharged into it, driven out 
by the great force with which the blood gushed forth. 

29th. — He had passed a pretty good night, and was free 
from pain, except in his left shoulder. Pulse reduced from 
from 140 to 120. Towards evening, he became somewhat 
delirious. He remained in this condition for eight days ; pulse 
ranging from 120 to 140, feverish, and at times out of his 
head. On the 4th of June, he was somewhat better. The 
bandages had been cut off, and the sponges removed from the 
wound, on the 2d. On the afternoon of the 4th, a sudden 
hemorrhage took place from the wound, amounting to eight 
ounces, and producing great depression : assistance being ob- 
tained, it was checked at once by plugging with sponges. 

On the 6th, at two o'clock in the morning, a third bleeding 
occurred, which w^as promptly stopped, about two ounces of 
blood only being lost. Some of the old sponges were removed, 
and replaced by fresh ones, dipped in the solution of the per- 
chloride of iron. From this time, he lost no more blood, and 
the wound suppurated well, the sponges being all removed on 
the 10th. From the attendant inflammatory action, his head 
was drawn down to that side, but gradually righted after the 
wound had fully healed. Before he left the Hospital, which was 
on the 2 2d, a piece of bone was discharged, which, on exami- 
nation, appeared to be the end of the transverse process of one 
of the cervical vertebras. 

He was seen a month afterwards, perfectly well. 



WOUND OF CRAXIUM. 555 

Case CCCXXXII. — Compound Fracture of Skull from 
Pistol-shot. Loss of Cerebral Substance. Death five 
days after. June 4, 1861, a man, 54 years old, Avas found 
lying in a shop, having attempted suicide with a pistol. The 
ball liad entered the head at about the middle of the right 
temporal fossa, making a large, irregular wound. 

Under ether, six hours after the wound was received, efforts 
were made to find the ball, and remove it. The wouikI was 
enlarged, and a pair of dressing forceps passed in, which met 
with no resistance until the opposite side of the cranium was 
reached. The ball could not be found. A piece of the roof 
of the right orbit, however, was extracted, which had been 
driven into the brain. The examination was made with great 
care, and occupied but a brief time. 

After the effect of the ether had passed away, the patient 
remained in a semi-conscious condition, but answered questions 
rationally when aroused. There were no signs of local or gen- 
eral paralysis, except in the upper eyelids, Avhich were fallen, 
and the eyes, which were protruding and fixed. The urine was 
passed without difficulty. The j^atient stated that he could see. 
In the evening, the eyelids became very much ecchymosed and 
swollen ; and about a tablespoonful of cerebral substance was 
discharo^ed from the wound. Durins; the nioht, he had sev- 
eral attacks of general subsultus : pulse 120, soft and regular. 
Brandy and water was given. 

5th. The subsultus diminished in frequency and severity : 
pulse 92, mind clearer. Has taken nothing but brandy and 
w^ater. 

6th. Passed a quiet night ; pulse 100, milk-punch ordered. 

7th. Rather weaker last night ; pulse 100, respiration 36, 
subsultus increasing, enema ordered. 

8th. Very restless last night, trying to get out of bed ; 
subsultus less, pulse 112, respiration 28, tongue dry; still says 
that he can see, but unable to raise eyelids. In the evening, 
he began to grow weaker, and sank into a comatose condition. 
After five o'clock the next morning, he failed rapidly, and died 
at half-past seven. 

The following is the report of the autopsy, made by Dr. 



556 GUNSHOT WOUNDS. 

Ellis: "Head, — dura mater of a reddish color, particularly at 
the posterior part ; considerable bloody serum between the dura 
mater and arachnoid ; large amount of blood beneath the arach- 
noid ; no flattening of the convolutions, swelling, nor other 
appearances of inflammation. The anterior portions and base 
of both hemispheres above the orbits were extensively, but not 
deeply, lacerated ; a thin layer only being softened and mottled 
on the confines of the injury. A small fragment of bone and 
a bullet w^ere found in the bruised layer. 

" A small portion of the left hemisphere outside of and above 
the lateral ventricles was softened, and filled with red points. 
A large opening existed above the right zygoma. The right 
orbital plate of the frontal bone was nearly destroyed, and the 
left badly fractured. 

" The surface of the ethmoid bone was also injured. An ir- 
regular portion of lead was found among the fragments of the 
left orbit. A fracture extended from the large opening on 
the right side, across the frontal bone." 

Case CCCXXXIII. — Reinarhahle Case of a Breech-pin, 
lodged in the JVa-sal Fossce for a great length of time. 
Fissure of the Hard Palate. Operation, Cure. — A man, 
35 years old, came under my care, who, seven years before, 
while shooting, had his gun explode ; the breech-pin flying ofl* 
and penetrating the head, producing a severe wound. The eye- 
ball was destroyed, the upper part of the socket crushed in so 
as to expose the brain, and an opening made in the back part 
of it, communicating with the nasal fossae. His recovery was 
very slow ; and he suffered much from pain in his head, and 
vertigo. The nose was obstructed, so that he was unable to 
breathe through it. 

Fourteen months afterward, a soreness was felt on the hard 
palate, and a foreign body seemed to close up the fauces. An 
investigation, being made, disclosed a screw projecting through 
the roof of the mouth. An incision was now made through 
the soft palate, by his medical attendant ; and the whole lost 
breech-pin, with the screw attached, was extracted. The model 
of the breech-pin, made by the patient himself, is now in my 



BREECH-PIN IN NASAL FOSS^. 557 

possession. It is three and one-quarter inches long, and three 
inches in circumference. 

The condition of the patient, when he entered the Hospital, 
was as follows : There was a fissure in the palate ; the eye- 
ball was gone ; the eyelids, apparently uninjured, remained 
open ; there was an opening at the back part of the socket, 
communicating with the nose and mouth ; the upper edge of the 
socket was irregular, where the bone had been destroyed, and 
the brain exposed. He could not speak intelligently without 
pressing his finger into the socket, and closing the lids, so as to 
prevent the passage of air through from the mouth. Even then, 
on account of the fissure in the palate, it was not easy to under- 
stand him. Swallowing was difficult, and required a certain 
position of the head to effect it. The first indication seemed to 
be to obstruct the passage of air through the socket. To effect 
this (the patient being etherized), the tarsal cartilages of the 
eyelids were removed, the cut edges brought together by su- 
tures, and collodion applied. His speech was at once improved 
by this operation. 

The following week, the fissure in the palate was operated 
upon. It required much dissection to bring its edges in con- 
tact, on account of the callous and unyielding condition of the 
soft parts. This was, however, finally effected, and the whole 
fissure closed. 

The first operation on the palate failed, from the patient's 
having persisted in chewing tobacco, and eating solid food. A 
repetition of it, however, with better behavior, was attended 
with success. The eyelids united, with the exception of a very 
small aperture, which, for a long time, resisted all attempts to 
close it, and gave issue to a glairy fluid, supposed to come 
from the remains of a portion of the lachrymal gland. The 
hole was finally reduced to so small a size that no air could pass 
through it. The patient left the Hospital quite well, with his 
voice almost completely restored. 

Dr. Henry G. Clark has kindly furnished me with the notes 
of the following case, which I saw at the Hospital : — 



558 GUNSHOT WOUNDS. 

Case CCCXXXIY. — Gunshot Wound in the Bach of the 
JSfech. Loss of Bone from Spinal Processes. Extraction. 
Recovery. — "The patient, Captain G., was wounded at the 
battle of Chickamauga, Sept. 19, 1863, by a Minie-ball, which 
entered the neck at the upper part, over the spine, passing 
forwards to the right until it found a deep lodgement under the 
right ear. Oct. 14, 1863, he entered the Massachusetts General 
Hospital. 

"He was a stout, healthy man, but had been suffering much 
from swelling and inflammation along the track of the ball, and 
down the neck under the angle of the jaw. There was a fistu- 
lous opening and a cicatrix behind the ear, the point at which 
several unsuccessful attempts had been made to extract the ball. 

"The patient being etherized, and the fistulous opening en- 
larged, the track of the ball was explored with the finger and 
forceps ; and several small pieces of bone from the spinous pro- 
cesses, and bits of cloth, were removed. The base of the occiput 
was discovered to have been grazed ; but the ball could not be 
found. An incision was then made into the fistula, below the 
angle of the jaw, and the ball found lying two inches below, in 
a sort of pouch, directly over and upon the carotid artery, and 
extracted by the forceps. It was grooved from point to base 
by attrition. From the extent and hardness of the swelling, 
the ball could not be felt externally. 

" The wound was thoroughly cleansed ; and the patient left 
the Hospital on Oct. 19th, rapidly convalescing, and afterwards 
wholly recovered." 

Case CCCXXXY. — Gunshot Wound of Nech. Ball ex- 
tracted three months after, at Base of Neck, in Contact with 
Spine. — At the battle of Fredericksburg, in May, 1863, an 
officer was struck,, by a plunging shot, on the left side of the 
lower jaw ; driving a portion of the bone, with three or four 
teeth, down into the neck, from which they were removed, some 
weeks afterwards, by an operation. The ball glanced down the 
neck, and disappeared apparently in the thorax. Some three 
months later, while he was partially recovering from the effects 
of his severe injury, a hard substance was felt, just above the 



WOUND OF NECK. 559 

clavicle, making its way upward between the two heads of the 
sterno-mastoid muscle. After moving up for half an inch, it 
was arrested, and remained stationary for one or two months, 
until October, 1863, when I first saw him. During this period, 
he suiFered from occasional pains in the left side of the chest, 
dyspnoea, and various symptoms indicative of nervous irritation. 
He was occasionally seized with severe pain in the left arm, with 
inability to raise it, lasting a while, and then passing off, but 
he had at no time the free use of the limb. On examination, 
the muscles being relaxed, in the depression between the two 
insertions of the sterno-mastoid muscle, a hard substance could 
be felt deep in the neck, lying on the bodies of the vertebras, 
and receding a little on pressure. 

The patient was etherized with great difficulty, it being one 
of those cases in which the ether causes great irritation of the 
lungs ; and it was only after a struggle of ten or fifteen minutes, 
that he became sufficiently quiet, from his cough, to allow the 
operation to proceed. The veins of the neck were, in conse- 
quence, much distended with blood. 

An incision Avas made, just on the outside of the great ves- 
sels, two or three inches in length, dividing a large vein in the 
course of the dissection, by which a slight delay was occa- 
sioned, chiefly owing to the struggles of the patient in breathing, 
and from fear of absorption of air in the violent movements 
of respiration. It was, however, soon tied, and the dissection 
continued downwards and to the outer side of the large vessels. 
The foreign body was now exposed, covered by a thick, white 
envelope, which was either the sac surrounding it, or the in- 
ternal jugular vein lying empty and flattened over it. A hole 
was therefore carefully scratched in it, when a quantity of white 
milky substance escaped, showing that the ball had been con- 
tained in a cyst or sac. The opening was then enLarged, and 
the bullet pried out from its lodging-place by the aid of a 
forceps and director. On passing the finger into the sac, it 
was found to reach the bodies of the vertebra. The bullet, a 
conical one, was flattened on the side wliere it had impinged on 
the bone ; and the cup-shaped cavity in its base was filled with 
a thick white paste, looking somewhat like mortar. It had 



560 GUNSHOT WOUNDS. 

apparently penetrated the chest to a certain extent, perhaps 
ploughing up the pleura, and had then gradually worked its 
way upwards, until it had reached the spot where it was found 
encysted. After a few days, during which there was some 
difficultj^^^of swallowing, recovery took place without other un- 
toward symptoms. 

He visited me, a year afterwards, in a good condition of 
health. 

Case CCCXXXYl.— Wound of Chest from Pistol-halls, 
Death eight years after. Pistol-balls suspended within the 
Chest by the Pleura. — In a fit of jealousy, a man shot his 
mistress, coming behind her while she was sitting on a low 
bench, and firing down upon the chest. He then placed a 
pistol to his heart, and pulled the trigger. In the act of dis- 
charging the pistol, the muzzle became a little elevated, so that 
the bullets just escaped the heart and great vessels in their pas- 
sage through the chest. Both these patients came under my 
care at the time. 

The woman lived three days, and then died in great agony. 
On a post-mortem examination, it was found that one of the 
bullets had passed through the cavity of the chest, and lodged 
in the body of a dorsal vertebra. This vertebra I now have, 
with the ball deeply embedded in it. A second bullet struck 
the first rib, was cut in two by it ; one half traversing the top 
of the rib, the other traversing the lung, being found loose in 
the cavity of the chest. The hemorrhage produced by this 
wound filled the chest, compressed the lung, and was the im- 
mediate cause of her death. The third bullet entered the neck, 
and its course could not be traced. 

The man, immediately on being wounded, had great emphy- 
sema of the walls of the chest, followed by entire flatness on 
percussion of that side. After a very severe illness, he recovered 
sufficiently to be brought to trial ; and, being convicted, was 
sentenced to the State Prison for life. 

I saw him at the prison about four years after. He then had 
a constant, dry cough. On auscultation, the respiration was 
found rough on the left side, and somewhat bronchial. There 



WOUND OF ABDOMEN. 561 

was no rale. Percussion revealed nothing abnormal. His health 
was otherwise o-ood. 

He died suddenly, eight years after the crime was committed. 
On examination, it was supposed by Dr. Morris, Surgeon to 
the Prison, that some disease of the heart would be found to 
explain his death. No sufficient disease, however, could be de- 
tected. The valves of the heart were thickened, but not enough 
to impede their action. In the upper lobe of the left lung, a 
cicatrix, showing the course of the balls, was distinctly visible. 
The balls, having traversed the lungs, had lodged in the side of 
the chest. From this place, they had become gradually de- 
tached, and were found suspended from the sides of the chest, 
like cherries hanging from a tree, having carried the pleura 
before them, and being enveloped in. that membrane. 

Case CCCXXXVH. — Gunshot Wound of the Abdomen, 
followed by Intestinal Fistula. Recovery. — At the battle of 
Chancellors ville. May, 1863, a strong healthy man, 25 years 
of age, was struck on the right of the abdomen near the umbili- 
cus by a musket-shot fired from an elevation. It penetrated the 
peritoneal cavity, passed through the pelvis, and came out 
through the middle of the right ilium. No very severe peritonitis 
occurred, and it was not until after several days that fecal matter 
appeared at the wound of exit. Pieces of bone were occasion- 
ally discharged from the same aperture. After several months, 
this wound healed, and discharges of pus and feces came away 
from the wound of entrance, in the front of the abdomen. I 
first saw the patient in January, 1864. He was in good health 
and spirits, with the exception of the annoyance from the wound 
just described, and a lameness in the right lower extremity, 
resulting from it. A small bougie, introduced into the wound, 
penetrated about eight inches in an oblique direction, when it 
encountered dead bone in the neighborhood of the pelvis. After 
one or two explorations with the bougie, a long pair of slightly 
curved forceps opening only at the extremity, and made of two 
branches rolling on each other, was carefully introduced, the 
edge of the bone seized, and small fragments of it removed. 
From a fear of wounding the intestines, however, the operation 

71 



562 GUNSHOT WOUNDS. 

was not persisted in. A poultice was applied to the cicatrix on 
the hip, which was thus made to open again; and, through a 
narrow callous fistula, the bone could be felt, by the forceps, 
somewhat beyond the reach of the finger. Portions of bone 
were ag'ain removed : but, as the main fra2:ment seemed to be 
angular in form, and was in the immediate neighborhood of the 
caecum, in which part of the intestine the opening probably 
existed, no further attempt was made ; the case being evidently 
one in which great caution was necessary. 

Early in March, the wound of exit w^as dilated so as to allow 
the forefinger to penetrate its whole length through the fistulous 
passage ; but the dead bone could not be reached. The forceps, 
being passed in, w^ould occasionally grasp the edge of the bone, 
which seemed to be attached to the pelvis, and involved in the 
folds of the intestine, from which it was dangerous violently to 
remove it. It w^as therefore decided to leave the case for the 
time to nature, with the hope that the fragment might escape 
per vias naturales. 

A few days after the last exploration with the forceps, a probe 
was introduced, and it was found that the fragment of bone had 
w^holly disappeared. Forty-eight hours later, on visiting the 
patient in the morning, he, in great delight, held up a piece of 
bone which he had passed the day before from the rectum, with- 
out pain or impediment to its passage. The fragment was 
semicircular in form, comprising a portion of both the inner and 
outer surfaces of the ilium, and measured about two inches in 
length, by three-quarters of an inch in breadth, looking not 
unlike a portion of the first rib. The discharge from both 
apertures at once diminished; and, at the end of a week, they 
were almost closed. He left the Hospital, March 28th, being 
advised to maintain the horizontal posture, and avoid much 
motion until the wound had become perfectly sound, and all 
danojer of tearino- throuo-h the adhesions was over. 

I saw this patient, in 1866, in a complete state of health. 
His wounds were healed, and no functional disturbance depen- 
dent upon tliem remained. I questioned him particularly as to 
colic, or other symptoms which might arise from a contracted 
intestine, but could discover nothino-. 



WOUND OF ELBOW AND KNEE. 563 

Case CCCXXXYIII. — Bullet passing through the Elhoic- 
joint, and lodging in the Knee-joint. Recovery. — A young 
officer, 25 years of age, while stooping down, at the battle of 
Antietam, to tie his handkerchief around the thigh of the man 
next to him, who was bleeding to death, his leg having been 
carried away by a cannon-ball, received a shot, which passed 
diagonally through his elbow-joint, and entered and lodged in 
his knee-joint. The elbow, at the time, was bent ; and, from 
the position he was in, laid flat against the knee-joint. A great 
s})out of blood at once took place from the inner wound in the 
arm, indicating that some large vessel had been cut oflf. He 
checked the hemorrhage with a leather strap, buckled tight 
around his arm. Of forty in his company, all but ten were 
killed or wounded. He limped off, on his injured leg, to the 
nearest ambulance station, where the wound in his knee-joint was 
examined by a surgeon. The probe penetrated the joint freely ; 
but the ball could not be detected. From the strongly bent 
position of the limb, it had apparently escaped the tibia, and 
passed in between the condyles of the femur, where it was 
securely lodged and concealed. His arm and leg had water- 
dressings applied, and were put in splints ; and he was imme- 
diately placed in the cars, and transported to Boston, where he 
arrived in the course of a week, with many other soldiers, some of 
whom had received equally serious wounds, and to whom the 
danger of transportation, except under existing circumstances, 
would have been considered almost a fatal movement. 

AVhen I saw him, he was in an extremely feeble condition. 
Belonging to a fresh body of troops, he had been marched, some 
days before the final battle, and fought for one or two days 
before, subjected to great heat ; his principal nourishment being 
green corn, which produced an almost constant diarrhoea. It is 
probable that to this condition he owed his safety. In addition 
to the above wounds, he was suffering from a contusion of his 
side. 

The knee-joint, I found, was free from pain and inflammation, 
but the wound on its outside slightly suppurated. It was dressed 
with a ham splint, and kept in a state of entire rest. On examin- 
ing the elbow-joint, I found it quite loose, both condyles broken 



564 GUNSHOT WOUNDS. 

off, the joint swollen, with an eiFusion on the inside, a bullet- 
hole below the joint on the outside, and above it on the in- 
side. The elbow was made immovable with splints : and, 
after a moderate amount of inflammation, which at no time 
amounted to any thing threatening, both the knee-joint and the 
elbow-joint did perfectly well ; so that, at the end of two months, 
he was able to go out of doors. He finally recovered all the 
motions of the elbow-joint. Now, at the end of four years, he 
walks without the least sign of lameness, the ball still remaining 
in the knee. The power of entire flexion of the leg only is 
wanting. 

Case CCCXXXIX. — Pistol-ball j)^ssing through Lungs. 
Itecovery. — Some years since, a man was brought into the 
Hospital, who had received, from a pistol in careless hands, 
a shot, which passed directly through the right side of the chest, 
and lodged under the integuments of the back. AYhen I first 
saw him, he was breathing with difficulty, in a deadly faint con- 
dition, his head having fallen on his chest; and he was spitting 
up freely frothy blood. He was very much depressed in mind, 
desired his wife to be sent for, and seemed to feel that his dis- 
solution was near at hand. I endeavored to encourage him as 
much as possible ; and, after having administered stimulants to 
bring up the circulation, removed the bullet from his back, and 
stopped the action of the chest by broad strips of adhesive plas- 
ter carried two-thirds around the body. He eventually recovered, 
after an attack of pleuritis and pneumonitis. 

The history of this man was a curious one. He had been to 
California on a gold-hunting expedition ; and, while there, had 
imagined that he could turn the waters of a small stream or 
river by means of an India-rubber tube, and thus expose the 
golden sand beneath. For this purpose, he had returned to 
Boston, and had caused to be manufactured such a tube, a 
hundred feet long:, and six or eioht feet in diameter. This had 
been nicely packed on board a vessel ; and he was on the point 
of sailing on his return, when the captain of the ship, playing 
with a pistol, accidentally shot him, as above related. 



WOUND IX THE GROIN. 565 

Case CCCXL. — Amimtation of Thig^h for Gunshot 
Wound, producing Fracture and Distortion of Thigh, and 
Anchylosis of ly nee-joint. Appearance of 13 one removed. — 
May 24, 1866, a young man, 20 years of age, entered the 
Hospital to have his leg amputated for gunshot wound of 
the thigh, received three years before, which had broken the 
thigh, and left it in a state of necrosis. The ball struck him in 
tlie back part of the thigh, rather below the middle, from which 
place a number of pieces of dead bone were extracted at the 
time. During the confinement, the knee-joint became anchy- 
losed. About a year before, he had an attack of erysipelas in 
the leg : and six months after, while jumping from a step, he 
struck his knee, and had not been able to use the limb since ; 
a distinct snap being heard in it at the time. There were some 
signs of a tuberculous deposit in his lungs. His left leg was 
shortened about five inches ; knee anchylosed ; the middle por- 
tion of femur was thickened, as if large quantities of bone Avere 
thrown out there. On the inner side of thioh was a cicatrix 
marking the point of entrance of the ball ; on the outer, one 
showing the point of egress, and a sinus, with dead bone, could 
be felt at this point. 

On the 29th of May, the thigh was amputated by small, oval, 
anterior and posterior flaps of skin ; the muscles being divided 
at the base of these by a circular cut. This patient recovered so 
as to be able to leave the Hospital in about four weeks. The 
following were the appearances of the limb removed : — 

The knee was bent, and the inner condyle anchylosed to the 
tibia, and the patella to the femur. The femur, where it had 
been broken by the ball, was overshot about three inches. In 
the upper part of the lower fragment, which was behind, was a 
circular aperture the size of a musket-ball. Masses of lead 
were here everywhere embedded in the bone. 

Case CCCXLI. — Case of Gunshot Wound in the Groin; 
the Ball lodging on the Capsule of the Hip-joint, and under 
the Great Vessels. Extraction three iveeks afterwards. He- 
covery. — Captain H. M., 23 years of age, at the battle of 
Gettysburg, on the second day, was stationed with his regiment 



566 GUNSHOT WOUNDS. 

in the Second Division, Second Corps, on the crest of the ridge 
occupied by the left centre of the army. During the morning 
of the third day, the enemy had massed his artillery opposite 
this front ; and, at one o'clock, opened upon it from 145 guns in 
position, for the purpose of clearing the way for the advance of 
his infantry. Our batteries replied, and a most terrific cannon- 
ade was kept up for nearly two hours, after which the assault was 
made ; and, the head of the enemy's column having penetrated, 
and obtained a lodgement, within our lines on the right of the 
regiment, the latter was ordered to change front obliquely to 
the right and rear, in order to meet it, and check its further 
advance. In this movement, and at short range, this officer 
received a bullet in his groin, at once disabling him. He was car- 
ried to the rear, where his wound was examined by a surgeon. 
It was probed, and a finger introduced ; but no traces of the 
ball could be found. He arrived in Boston about a week after- 
wards, in a state of great suffering. The wound was a little 
below Poupart's ligament, the swelling not excessive, but the 
motions of the joint extremely painful. 

He was placed in a position where the limb could have the 
most perfect rest, and applications used to reduce inflamma- 
tion ; but, after two weeks, symptoms of acute inflammation 
of the hip-joint coming on, and the pain becoming almost ex- 
cruciating, I cut down and removed the ball, which had taken 
somewhat an irregular course, lying directly upon the capsule 
of the hip-joint, which had not, however, apparently been pene- 
trated. The patient was then put upon a fracture-bed, com- 
posed of a triple inclined plane placed on a second plane, 
similar to the one used in a case of fracture above, so that the 
whole body could be moved without disturbing the joint. In 
this position he remained for many weeks, being unable to allow 
any one even to touch the bed without experiencing great 
suffering, and requiring the use of ether when his clothes were 
changed. 

At the end of one or two months, the inflammation having 
subsided, I broke up the adhesions to the joint, while he was 
under the Influence of ether. He did well, and got on crutches ; 
but, from an accidental fall, not being sufficiently careful in the 



WOUND OF THIGH. 567 

use of his crutches, the joint was wrenched, and the inflam- 
mation reproduced. 

He uhimately recovered with a completely straight limb, but 
stiffened hip-joint, being unwilling to submit to the confinement 
and uncertainty offered by another operation to loosen it. 

Case CCCXLII. — Gunshot Wound. Fracture in Right 
Femur, at its Upper Third. Great Suppuration. Con- 
finement for nearly a year. Great Distortion. Operation 
for N^ecrosis. Subsequent Death from Exhaustion. — A 
distinguished oflficer of artillery was shot before Petersburg, 
June 18, 1864, by a Minle bullet, which passed through his 
left thigh, and penetrated the right, near the fold of the nates. 
He was carried to a Hospital; and, at the end of four weeks, 
the bullet was extracted. He suffered much from his wounds, 
and from bed-sores, which formed on his back. At the end of 
four weeks, he was taken to his home in Maine, in an exhausted 
state, where he began shortly to improve. Four weeks after 
this, while endeavoring to turn in his bed, he heard a loud snap ; 
and immediately his right foot became inverted, and his thigh 
shortened two or three inches. In this condition he remained 
until May, 1865, nearly ten months and a half after the receipt 
of the injury, when he was brought to Boston, and placed in a 
private room at the Hospital, under my care. He was then 
very feeble, with a great discharge from the wound in the outer 
and upper part of right thigh, and apparently failing. The foot 
was strongly everted, the limb shortened, the knee-joint partial- 
ly anchylosed, and he could not be moved in bed without the 
greatest difficulty. He was kept alive only by means of food of 
the most nourishing character, and large quantities of stimu- 
lants. 

A consultation being held on his case, the question was pro- 
posed whether to amputate the limb near the hip-joint, or to 
make an attempt to remove the dead bone ; and it was decided 
to attempt the latter. On the 7th of May, a free incision was 
made on the outside of the thigh; and a large sequestrum, 
locked in between the upper and lower fragments, was success- 
fully removed. On removing the sequestrum, it was found that 



568 • GUNSHOT WOUNDS. 

the upper and lower fragments touched each other, but were 
united only for a space of about a quarter of an inch in cir- 
cumference. It was therefore decided to attempt to remedy the 
great deformity and shortening which existed. This was done 
by slightly twisting the foot, and the adhesions easily gave way. 
The foot was then brought up into a proper position, and, by 
extension, the shortening reduced to one inch. The limb was 
next carefully secured by splints and bandages, and the patient 
transported to his bed. He passed a comfortable night, and for 
a time seemed to improve. Two weeks afterward, however, he 
had some hemorrhage from the wound. He gradually failed, 
being worn out with the combined effects of suppuration, bed- 
sores, and the bleedings which occurred, — which last, under 
other circumstances, would have been of no consequence, — and 
died May 28th. 

A.iUopsy. — The upper fragment, about five inches in length, 
was turned outwards and downwards ; and, at about two and a 
half inches from its apex, there was a rough, irregular surface, 
the seat of its attachment to the lower fragment before the op- 
eration. Its contour was quite irregular, and showed signs of 
previous disease, as also the marks of pressure made by the 
pointed end of the lower fragment. The latter was very irregu- 
lar in aspect, having cavities left by the removal of the seques- 
trum. The interior of the bone was completely disintegrated 
for some four or five inches, a sanious discharge oozing from it. 
The angle made by the two fragments was very strongly marked. 
The adjacent part of the thigh was completely riddled with bur- 
rows, one of which extended as high up as the crest of the 
ilium. 



CHAPTER XIII. 

MISCELLANEOUS CASES. 

PENETRATING WOUNDS OF THE CHEST AND ABDOMEN. 

These are rare in civil practice, but I have met with several 
dangerous wounds implicating the cavities of the chest and 
abdomen, — more especially the former, — which, contrary 
to the usually received opinion, have recovered under judicious 
care and management. Since the war, important discussions 
have been held on this subject ; and in cases, for instance, where 
balls had passed through the chest, followed by recovery, the 
diagnosis has been questioned. I was glad to find, however, 
that many distinguished surgeons had been brought to the same 
conclusions, in the great field of inquiry which was offered to 
them by the war, that I had already arrived at by the small 
experience in these wounds presented by civil practice. 

The experience of the late war also shows, contrary to the 
popular opinion, the rarity of wounds by the sabre and the bayo- 
net. Out of 87,822 wounds that were classified, there were 
106 sabre wounds and 143 bayonet wounds : 11 died of the 
former, and 6 of the latter, making 17 in all. 

Guthrie, one of the most distinguished of English military 
surgeons, testifies to the great rarity of this description of 
wounds. 

In illustration of the above remarks, I would quote from Cir- 
cular No. 6 the followin"^ results of c^unshot wounds in the 
chest ; and although It may be said that these wounds are 
different from wounds made with a pointed weapon, yet the 
danger would be in favor of the foi*mer : — 

" Of 7,062 gunshot wounds of the chest which have been examined, 
and transcribed from the reports belonging to the period prior to July, 

72 



570 MISCELLANEOUS CASES. 

1864, there were 2,303 that either penetrated the thoracic cavity or 
were accompanied by lesions of the thoracic viscera. The results have 
been ascertained in 1,272 of these, and were fatal in 930, or 73 per 
cent. The 4,759 flesh-wounds presented a very small ratio of mortal- 
ity. It was observed, however, that they were commonly long in heal- 
ing, in consequence, no doubt, of the mobility of the thoracic parietes. 
" Of 2,707 gunshot wounds of the abdomen, reported from the be- 
ginning of the war to July 1, 1864, there were 2,164 flesh wounds, 
and 543 cases in which the peritoneal cavity w^as penetrated, or the 
abdominal viscera injured. Among the flesh-wounds, 114 fatal cases 
are reported, which were, in most instances, cases of sloughing, from 
injuries of the abdominal parietes by shells. Of the 543 penetrating 
wounds, the results have been ascertained in 414, and were fatal in 
308, or 74 per cent. The number of recoveries is unexpectedly large, 
but includes only cases in which the reports showed, beyond question, 
that the abdominal cavity had been involved." 

The following cases, -which happened to be in the Hospital 
under the care of my colleague, Dr. H. G. Clark, and myself, 
in June, 1859, (the notes of which I made immediately after- 
awards,) are cited in confirmation of what I have now said : — 

Case CCCXLIII. — S tab in Abdomen. Recovery, — The 
first case was that of a young woman, about 25 years of age, 
under the care of Dr. H. G. Clark, wdio, about a month be- 
fore, received a stab on the upper and left side of the abdo- 
men from a drunken soldier. The knife cut through all her 
clothes ; made an incision from three to four inches in length 
in the upper part of the abdomen, through the skin, fat, and 
muscles ; and apparently penetrated the abdominal cavity. The 
wound was brought together by stitches, and the patient sent 
to the Hospital, where she arrived in a state of great exhaustion 
and suffering. 

A few days after her entrance, the Avound w^as attacked with 
erysipelas ; and she underwent a very critical inflammation of 
the abdominal parietes. The peritoneum, however, seemed to 
escape ; and she recovered well. 

Case CQC^IAY. — Stab in Chest. Recovery. — The sec- 
ond case was a sailor, about 25 years of age, also under Dr. 



PENETRATING WOUNDS OF CHEST AND ABDOMEN. 571 

Clark's care. About two weeks before, in a drunken fray, he 
received a stab from a large knife in the chest between the sixth 
and seventh rib of the right side, also a second stab in the 
upper part of the abdomen. He was at the time suffering under 
an attack of an asthmatic nature. The wound in the chest 
penetrated through the ribs, cutting off the inferior intercostal 
artery, which bled furiously, and, when he entered the Hos- 
pital, could only be stopped by thrusting a bit of sponge into 
the wound between the ribs. This effectually staunched the 
bleeding. The wound in the abdomen gave no symptoms. At 
the end of three days, a poultice being applied over the sponge, 
it softened and came away without hemorrhage. The patient 
during this time was very asthmatic, and the action of the lung 
on that side seemed nearly suspended. He expectorated freely 
a muco-purulent matter, but attributed his symptoms principally 
to previous disease, and recovered without further bad symp- 
toms. 

Case CCCXLV. — 8tah in Neclc and Abdomen. Recov- 
ery. — The third case was that of a young man, 19 years of 
age, who, the day after leaving the House of Correction, engaged 
in a brawl, and received a stab in the left side of the neck and 
upper part of the abdomen. The omentum escaped from the 
abdominal wound, but, being returned by the physician first 
called, the wound was sewed up ; and this, as well as the wound 
in the neck, which had cut through the mastoid muscle without 
injury to any important artery or nerve, was closed with adhesive 
plaster. 

The patient was placed on his back, kept on oatmeal gruel, 
and no medicines used. He had no tenderness of the abdomen, 
no fever, and, at the end of a week, appeared perfectly recov- 
ered. I kept him very quiet, from fear lest adhesions formed 
between the omentum and abdominal parletes might be torn 
away, and serious symptoms induced by too early and too active 
movements. 

Case CCCXLVI. — Stab in Chest. Recovery. — The 
fourth case was an Italian, 20 years of age, stabbed in tlie chest 



572 MISCELLANEOUS CASES. 

by a drunken man. The wound was large, and appeared quite 
deep ; it was situated just on the edge of the false ribs. Either 
from fright or bleeding, the patient, when first brought into the 
Hospital, had the aspect of having received a mortal wound. 
But on the following day, no symptoms in the lungs having 
appeared, I was convinced that the knife had passed between 
the integuments and ribs, and that the viscera of the chest and 
abdomen had escaped injury. I did not, however, make any 
examination, in this or in the other case, with a probe, — 
a practice which I consider unnecessary, intermeddling, and, I 
may almost say, criminal ; as it might in some instances com- 
plete the passage of the wound into a large cavity which other- 
wise might have escaped, or the screwing of the probe round 
in the chest or abdominal cavity might of itself be productive 
of serious consequences. 

This last patient also did well. 



HIP AND SPINAL DISEASES. 

The present improved method of treating hip and spinal dis- 
eases may be adduced as one of the greatest triumphs of the 
modern school of pathology. Hip-disease, as every one knows, 
was formerly treated almost exclusively as a local inflammation ; 
and the patient was confined to his bed, tormented in turn by 
the severe pain caused by every motion of his diseased joint, 
and by an appalling routine of leeches, cups, blisters, setons, 
and issues. Dr. Physick, of Philadelphia, demonstrated the 
great importance of rest ; which he secured by means of the 
"carved splint," accurately fitted to the hip, and confined by 
bandages. The carved splint is, however, an expensive ap- 
pliance ; requiring to be made expressly for the case in which 
it is to be employed. The full benefit, therefore, of this 
treatment was only realized after the introduction of splints 
of gutta percha, at the Hospital, some twelve or fifteen years 
ago. The rest thus secured by the immobility of the apparatus 
affords immediate relief from pain, and, with the aid of baskets 
which I have had made for the purpose, admits, even in bad 
cases, of the patient's being readily carried into the open air, 



HIP AND SPIXAL DISEASES. 573 

or even transported great distances. The recent invention of 
the improved instruments of Drs. Davis and Sayre, which, in 
many cases, admit of a moderate degree of locomotion, has 
given a new impetus to the treatment of this disease ; avoiding, 
in even a greater degree than before, the injurious confinement 
in bed to which the patient was formerly condemned. In those 
cases where no splint can be borne, great relief is experienced 
either by the application of a simple weight attached to the foot, 
or the extension apparatus of Desault, to separate and prevent 
friction of the inflamed surfaces. The constitutional treatment 
must, of course, be directed to the preservation of the strength 
during the course of a long and tedious disease ; and it is by 
the mechanical appliances just mentioned that we are enabled to 
avail ourselves of the inestimable benefits of fresh air and, gen- 
tle exercise, so essential to the maintenance of health both of 
body and mind. 

Caries of the spine naturally falls into the same category as 
hip-disease. Mechanical support should be given to the back, 
in order to prevent the breaking-down of the inflamed vertebrae 
from the weight of the upper part of the body : the patient is 
thus enabled to move about, and preserve a fair degree of 
health during a long and trying disease. 

Many scrofulous aflections of the knee, and other large joints, 
are to be treated according to the same principle ; sustaining the 
system by invigorating remedies, and securing immobility of the 
aflected joint by proper mechanical appliances. 

It is still a question how far we can safely venture in at- 
tempting to destroy the adhesions, and consequent immobility, 
caused by disease of the hip and other large joints. Some ex- 
periments have been tried, with a view to deciding this point ; 
but the rule of practice is, as yet, by no means settled. 

I have, however, seen in the practice of Dr. B. Brown, of 
this city, and assisted him in the operation upon, a number of 
cases of children suffering under false anchylosis of the joint, 
the sequel of liip-disease, in which the adhesions have been 
broken up under ether with gratifying results. 

The diagnosis of incipient hip-disease is a subject of mucli 
importance, and sometimes a matter of considerable difficulty. 



574 MISCELLANEOUS CASES. 

there being such a variety of symptoms connected with it. Gen- 
erally, there is a pain in the knee-joint ; sometimes, though more 
rarely, in the hip itself. In others, there is a complete immu- 
nity from pain, and the only symptom is lameness. The follow- 
ing method, for clearing up this point, I have seldom known to 
fail : — 

The patient being laid upon the back, and the limbs well 
relaxed, the sound limb is first seized, and freely bent until 
it nearly or quite touches the abdomen. The same manoeuvre 
being attempted with the other limb, it will be found that the 
flexion of the limb is almost invariably arrested at or near a 
right angle with the body ; though I have seen one or two ex- 
ceptions to this rule. If the flexion Is complete, and if, added 
to it, there is no pain from deep pressure in the groin, the 
cause of the lameness may be searched for elsewhere. 

A question, which has been much discussed, is, why is 
the diseased limb apparently lengthened in some cases, and 
shortened in others. So far as I have observed, the following 
is the explanation : When the disease comes on insidiously, and 
with but little pain, so that the patient is able to keep about, the 
limb is carried in front of the other in walking ; and the pelvis, 
in this way, gradually becomes depressed. When the affec- 
tion is acute, and attended with much suffering, the patient lies 
in bed on the sound side, drawing up the affected limb ; that 
being the most comfortable position in this, as in some other 
inflammatory affections of the lower extremities. 

Hip-disease is not unfrequently mistaken in children for dis- 
location of the hip-joint ; and I have had a number of cases 
under my care, of patients who have suffered an aggravation of 
their disease from attempts having been made to reduce a sup- 
posed dislocation, the symptoms of which had come on not long 
after the receipt of a fall. The diagnosis is at once cleared by 
the use of ether, which relaxes the irritated muscles, and re- 
moves the distortion. 

I do not propose to adduce cases in illustration of this very 
common affection, but would reiterate what has already been 
said in regard to keeping the joint in a state of perfect rest, by 
such appliances as will allow the patient to enjoy the invigorat- 
ing influence of the open air. 



GANGEENE OF THE APPENDIX VERjMIEORMIS. 575 



APPENDIX VERMIFORMIS. 

Case CCCXLVII. — Gangrene of the Ajjjjendix Ver-mi- 
formis. — 1851, June. The patient, a gentleman 40 years of 
age, had always been subject to what are called bilious com- 
plaints. About four years before, he Avas confined for some 
weeks to the house by a severe attack of colic, attended with 
constipation, at which time I observed a small, hard tumor — 
tender on pressure — in the right lumbar region. Two j^ears 
later, in October, he had a second attack, in which the pain was 
excruciating, and required the constant inhalation of ether and 
the use of opiates to relieve him. At this time, there was a 
diffuse swelling in the right iliac and lumbar regions, quite 
hard, and very tender. Under the use of leeches, and by in- 
ducing a slight mercurial action on the system, he slowly re- 
covered. Fearing some organic complaint, not only from the 
swelling, but from his great susceptibility to cold and disturbed 
digestion, I advised him to relinquish business ; at least so far 
as to allow him to have his mind perfectly free from any care, 
and to give him an opportunity of paying particular attention 
to his health. This he did, and Avas quite free from any trouble 
until the final attack, which came on after exposure to cold, and 
some irregularity in diet. The pain, for a day or two, amounted 
merely to a feeling of uneasiness, but gradually became exces- 
sive. A tumor could be distinguished at this period in the 
rioht iliac fossa, about the size and leno-th of the forefinirer : it 
was quite hard, and could be almost seized through the integu- 
ments, and lifted up. The pain and tenderness were so great 
as to require the overpowering use of opiates administered by 
enema. 

On the third day, there was a slight evacuation from the bow- 
els, by means of an enema ; but the patient shortly after fell 
into a state of collapse, and died seventy-four hours after the 
violent seizure. For the last twenty-four hours, there was 
the most distressino' hiccouo-h. 

o o 

An examination, after death, revealed extensive peritoneal 
inflammation. There was verv ^reat induration of the omen- 



576 MISCELLANEOUS CASES. 

turn, with firm adhesions, arising apparently from the previous 
attack, two years before. Some purulent matter escaped from 
the cavity of the pelvis. The appendix vermiformis was found 
gangrenous, and perforated at both ends : in its central portion 
was contained a mass of indurated feces, as large as a prune- 
stone. On section of this substance, no nucleus could be dis- 
covered. 

It is well known, that small shot, apple-seeds, and various 
other foreign substances, lodging in the appendix vermiformis, 
will give rise to the above symptoms ; though, in post-mortem ex- 
aminations of persons dying of other diseases, these substances are 
often found there, not having caused any disturbance during life. 

Case CCCXLVIII. — JVecrosis of Bones of Skull giving 
rise to a Tumor containing Air. (See Plate Y.) — A man 
from New Hampshire applied to me for advice on the 28th of No- 
vember, 1861. Four years before, he had received a severe blow 
on the forehead, from a heavy branch of a tree. Great swelling 
ensued, which confined him to tlie house for a week or ten days. 
The swelling gradually subsided, leaving a sensation of dull pain 
in the part, accompanied, from time to time, by soreness and 
tumefaction. In July, 1861, while at work in the hay-field, he 
was seized with severe headache, and other symptoms indicative 
of cerebral disturbance. Soon after this attack, a tumor ap- 
peared over the seat of the original injury, covering nearly the 
whole forehead. After a great deal of sufi'ering, a discharge of 
pus took place from the left nostril, and afibrded him temporary 
relief. Subsequently, the tumor became tense again, and was 
opened with a lancet, which gave vent to a small quantity of 
purulent matter : a second operation resulted, as he says, in the 
escape of blood only. His sufferings continued to increase until 
the date of his visit to me. At this time they were so excessive, 
and the constitutional symptoms of such a character, as to lead 
him to the conviction that his case was altogether hopeless. 

The whole forehead was occupied by an elastic swelling, of 
the size of half of a large orange, partially divided in the centre 
by a vertical depression, caused apparently by the tendon of the 
occipito-frontalis muscle. The marginal base of the tumor 



V. 



--wSSi*- 







NECROSIS OF SKULL. 577 

seemed to be formed by an elevation of bone, about an inch 
high, as if the tumor had been forced out from within the cavity 
of the cranium, pushing the bone before it. By pressing firmly 
upon the upper part of the tumor, irregular masses of bone could 
be distinguished ; some of them loose, others forming bridges 
under which the iluid contents of the tumor could be forced with 
a gurgling sound. It was higlily resonant on percussion. Air 
could be readily forced into it from the nostrils, and the tension 
thus imparted to it remained for a long time ; owing, probably, 
to the interposition of a piece of loose tissue, acting like a valve. 
During violent exercise also, the tumor generally became inflated. 

The diagnosis was a collection of pus, beneath the occipito- 
frontalis muscle, communicating with the frontal sinuses ; but 
whether it originated from periostitis, or from disease of the 
diploe, or from a tumor arising within the cranium, appeared 
doubtful. 

Operation, yov. 30fk. — The patient was etherized, and an 
incision made in the median line laro-e enouoh to admit the 
finger. A quantity of air escaped ; and the finger, which was 
passed into the wound, detected the fact that the bone was every- 
where in a carious state. The incision was then extended, and 
crossed at right angles by another, so as to expose a large sur- 
face of the diseased bone. The whole external table of the 
frontal bone was much thickened, and in process of exfoliation. 
A probe passed readily into the frontal sinus, and from thence, 
with some management, into the left nostril. The patient, on 
recovering from the eftects of the ether, was able to force air 
freely through the wound. Blood escaped also into the nasal 
cavities. The apparent elevation of bone around the tumor was 
not owing to an expansion of the outer table of the skull, as at 
first supposed, but to inflammatory action in the soft parts ; a 
deception similar to that which is often found to follow blows on 
the head, causing an appearance frequently impossible to distin- 
guish from a depression of the bone. In the present case, the 
illusion was perfect. A compress was applied between the lips 
of the wound, v» hich was left open to favor the separation of the 
necrosed bone. The patient was immediately relieved from pain, 
and the following night slept better than for six months before. 



578 MISCELLANEOUS CASES. 

The fifth day after the operation, it was found possible to detach 
some large plates of bone, which were sufficiently movable to be 
taken away without violence. In the course of another week, 
the patient went home, entirely free from pain, and in good 
health : it was thought unnecessary to detain him longer in 
town, as the exfoliation of the carious bone would probably re- 
quire a long time for its completion. 

A month or six weeks later, he made a second visit to Boston, 
when, after ^considerable manipulation, another long and thick 
piece of bone was removed from near the centre of the os frontis. 
The anatomical appearance of this fragment led to the supposi- 
tion that it might be made up of both tables of the skull. No 
bad symptoms followed its removal, and the suppuration of the 
wound was much diminished by it. His health appeared to be 
excellent. 

He again came to Boston, on account of a purulent collection 
under the integuments of the forehead. This being relieved by 
an incision, loose bone was again removed. 

Since the above record was made, I was consulted by him on 
account of a remarkable deposit in the cellular tissue in one 
of the upper extremities. There was a great depreciation in 
health, and a disposition to cerebral disturbance. 

Guthrie, in his valuable work, " Commentaries on the Surgery 
of War," refers to a tumor of this description, and in precisely 
the same situation as the one above described, as follows : — 

" After a wound of the frontal sinus has healed, the air has been 
known to raise up the integuments of the forehead into an elastic 
crepitating swelling, whenever the patient blew his nose, so that a 
compress and bandage on the part were required for its rehef ; but 
these cases are very rare." 

Case CCCXLIX. — Poisoning hy Nitric Acid. Death. 
Autopsy. — A negress, 34 years of age, of abandoned charac- 
ter, thinking that she was three months pregnant, took nitric 
acid at 6, p.m., on the 3d of March, 1850, for the purpose of 
destroying her child. The quantity taken into her mouth was 
reported to be 5iij, but most of it was spit out. Alkalies and 
mucilaginous drinks were used ; but the burning in the mouth 



POISONING BY NITRIC ACID. 579 

was intense through the night, with restlessness and delirium. 
The next morning she Was brought from the jail, where the 
acid was taken, to the Hospital. Yellow stains were then ob- 
served upon the clothing, and the whole inside of the mouth 
and fauces, so far as could be seen, was of a deep yellow 
color, the tongue looking as if covered with Indian meal ; the 
respiration being painful, labored, and stridulous, and speech 
almost impossible. Extremities cold, countenance of a leaden 
hue ; pulse 120, and very small. For the first four or five 
days after her admission, she suffered from soreness of the 
mouth and throat, dysphagia, thirst, and salivation, with some 
vomiting : she also complained of tenderness of the abdomen, 
but not particularly over the stomach, walking with difficulty, 
and bent much forwards ; but this was perhaps owing to her 
having been thrown down and stamped upon, in an affi'ay, on 
the day on which she took the acid. After the first day or 
two, she was much of the time up, and about the ward; at 
the end of a week, she was reported quite comfortable, and 
having some appetite ; and, on the 14th of March, as she 
was doing well, she was removed back to the jail, there never 
having been any fever, but rather a state of depression. On 
the morning of the 16th, she was attacked with cramps in the 
stomach, and excessive pain and tenderness, which were partially 
relieved by opiates : on the following morning, however, she 
was found dead in her cell, with a great quantity of blood in 
the bed about her, which she had apparently vomited. 

On dissection, there was observed great rigidity ; upon the 
middle of the tongue a large, yellowish, smooth patch; some 
redness of epiglottis ; oesophagus healthy for the first two in- 
ches, but, below this, it was found exceedingly soft, of a greenish 
yellow color internally, purple externally, and full of coagu- 
lated blood. The stomach was in a similar, though much worse 
state ; externally, it had the same purple color, and was univer- 
sally adherent to the neighboring parts by recent lymph, except 
at the left extremity, where there were old and close adhesions 
to the spleen ; internally, it was of a greenish yellow color, em- 
physematous, and so perfectly softened and friable that it could 
not be separated from the surrounding parts without giving way 



580 MISCELLANEOUS CASES. 

in every direction, the anterior face being detached from the 
rest of the organ to a great extent, when the abdominal parietes 
were raised ; its cavity was filled with recent coagulated blood, 
and the open orifices of several vessels were distinctly seen on 
the inner surface. The intestine contained blood throu^-hout 
the first two or three feet, but was otherwise well, as were the 
other organs, so far as observed ; uterus not gravid. 

These symptoms are very similar to those described by Mr. 
Taylor as occurring from this substance. He says that poison- 
ing by nitric acid is very rare, and that Tartra has only been 
able to collect fifty-six cases, extending over a period of nearly 
four hundred years. Death usually takes place rapidly. Out 
of twenty-seven cases reported by Tartra, nineteen were rapid, 
eight slow. Death is sometimes immediate, from its eifects on 
the larynx. The usual period is about twenty-four hours. 
In one case, a patient lived three months, and, in another, 
eight months ; in the former case, great contraction being 
found about the pyloric orifice of the stomach, and the duo- 
denum equally contracted. The case now reported may be 
placed among those in which the fatal event was unusually pro- 
tracted. 

Case CCCL. — Painful Crepitation of the Tendons. 
— March 8, 1866, a lady called on me supposing that she had 
a fracture of the right radius ; there being a swelling over that 
bone (commencing about two inches above the wrist-joint), 
attended with a crepitating sound on motion of the hand, which 
motion gave her much pain. The only cause she knew of was 
making an effort to raise the window of a car. 

On examininof the swelling^, it was found to be from two to 
three inches long, very slightly elastic, somewhat painful on 
pressure, but more painful when the hand was extended. At 
this time, a dry crepitus could be distinguished, and felt by the 
patient herself, which could easily be mistaken for the rubbing 
together of the fractured ends of a broken bone. 

I at once detected the nature of the affection, two cases of 
which I had described, in 1843, in the " New-England Quar- 
terly Journal of Medicine and Surgery," and also in the " Eec- 



PAINFUL CREPITATION OF TENDONS. 581 

ords of the Boston Society for Medical Improvement" in 1857, 
both of which are given below. 

I advised her to keep her arm perfectly quiet in a sling, and 
foment it every night by means of a piece of spongio-piline 
soaked in warm water. At the end of three weeks, the symp- 
toms had almost entirely disappeared. 

Case CCCLI. — Painful Crepitation of Tendo7is. — The 
patient was engaged in arranging some window-curtains. While 
standing on the top of a flight of stairs, from a sudden jerk her 
foot slipped, and the hand was caught in the curtain-rod, flex- 
ing very powerfully the wrist, wdth the whole weight of the 
body bearing on it. At the instant, she felt a slight snap on 
the lower and back part of the arm, near the wrist. This was 
followed by considerable pain and swelling, and she was sup- 
posed to have sustained a fracture of the radius. I saw her the 
next day. At this time the arm presented the following appear- 
ance : On the back part of the arm, just over the head of the 
radius, was a small swelling, a little red and painful on pres- 
sure. By placing the finger on the prominence, and flexing the 
hand, a distinct crepitus w^as perceived, wdiich at first might be 
taken for the grating of bone, but, on a little examination, was 
perceived to be quite different ; being a more dry and distinct 
sound, somewhat similar to the rubbins^ too^ether of coarse brown 
paper, and compared by Velpeau to the sound which we hear 
from the rubbino^ too-ether of inflamed serous membrane, — the 
pleura, for instance. The sensation is at first quite startling, 
and is distinctly perceived by the patient, and, when once dis- 
criminated by the surgeon, is not easily forgotten. In the pres- 
ent case, the greatest crepitus was heard, and the most pain 
caused to the patient, when the thumb was flexed. 

A number of explanations have been offered as to the cause 
of the crepitus. The most reasonable, and undoubtedly the 
true one, is that of Yelpeau, which is the friction of the tendon 
against the dry synovial sheath ; its fluid being deficient from the 
inflammation consequent on the injury. Somewhat a similar 
grating sound is often perceived by moving the patelhi in a cer- 
tain stage of synovial inflammation of the knee-joint. The 



582 MISCELLANEOUS CASES. 

disease is most frequently found in persons whose occupation 
produces a great strain on the joints, such as blacksmiths, 
stone-cutters ; also in washerwomen, being caused by twisting 
clothes. It occurs in the ankle as well as in the wrist joints. 
The disease yields to treatment in about ten or fourteen days, 
as in the present case ; no pain or crepitation being perceptible 
after a fortnight. 

Case CCCLII. — Painful Crepitatio7i of Tendons. — A 
woman employed in wringing out clothes was seized with a 
severe pain in the back part of the arm, near the wrist, which 
became swollen. I saw her on the following day. A swell- 
ing and redness then extended up the arm toward the elbow- 
joint, very painful to the touch, and on motion. On rotating 
and flexins: the hand and fore-arm, the fino-ers beino; on the 
injured part, the peculiar sound alluded to was perceived. It 
was perfectly dry crepitus, which at first might be mistaken 
for that of a fractured bone by one who for the first time ob- 
served it. In those cases where the accident had occurred to 
the long head of the biceps, it had been mistaken for a fracture 
of the neck of the humerus. 

The symptoms lasted about fourteen days, and yielded to rest 
and antiphlogistic remedies. 

This affection I have not seen described in any of the Eng- 
lish surgical works : it has been treated of by Velpeau under 
the name of " Crepitation Douleureuse des Tendons," and is a 
disease of some practical interest. 

Partial Eupture of the Tendon of the Quadriceps 
Extensor Femoris Muscle. — The complete rupture of this 
muscle, or rather of its tendon, is at once so patent, from its 
symptoms, that there is no mistaking the nature of the treatment 
to be pursued, and a case of it has already been given above. 
Partial rupture, however, of this tendon near the patella is often 
at first not marked by any symptoms whatever, or else by signs 
so obscure as to make it very difficult to determine the true 
nature of the accident. As instances of this accident, I would 
mention the followins: cases : — 



PARTIAL RUPTURE OF TENDON. 583 

Case CCCLIII. — A gentleman about 55 years of age, 
of large and powerful frame, applied to me on the 29th of 
November, 1864, on account of a lameness of the right knee, 
of which he o^ave the folio win o^ account. Between one and two 
years before, while kneeling on the sand by the seashore, he felt 
a sudden pain shoot through his knee. No symptoms of any 
consequence followed until three months after, when he began 
to be a little lame. There was soreness about the knee, some 
slight difficulty in extending the leg, and in going up and down 
stairs. The limb was rubbed in the usual way with liniments, 
&c., but without marked effect. As time went on, neuralgic 
pains were felt in different parts of the limb, both in the thigh 
and leg, and the limb became obviously more flabby and smaller 
than its fellow. On examining the knee, I at once discovered, 
just above the patella, a distinct depression or fissure, about an 
inch long, in the extensor tendon, and penetrating, as it ap- 
peared, through about half its substance. At this point, there 
was a little redness of the skin, and a puffiness not to be dis- 
tinguished above the other knee. The muscles both of the 
thigh and leg were quite soft, and measured one inch less in 
circumference than its fellow. I advised the patient to wear a 
leather laced stocking extending from the ankle to the hip, and 
fitted accurately to the limb, to use a cane in walking, and to 
stand as little as possible ; also to employ bathing and frictions. 
In case of an aggravation of the symptoms, I also advised him 
to do what he now altogether refused, — to have a splint ap- 
plied, and to keep perfectly at rest. I was glad to find after- 
wards, that my diagnosis was confirmed by Professor Willard 
Parker of New York, who had previously examined the case. 

Case CCCLIV. — Several years since, a young gentleman 
was seen, in consultation, by Dr. J. C. Warren and myself, to- 
gether with the physician of the patient, on account of an acci- 
dent to the knee, which had occurred six months or a year 
before. In making some violent effort, a slight crack was felt 
in the neighborhood of the joint, followed by some lameness and 
tenderness. At the time, nothing could be distinguished upon 
examination. Various methods of treatment were tried without 



584 MISCELLANEOUS CASES. 

effect, and the patient, becoming gradually lamer, was brought 
to Boston for advice. A very careful inspection of the parts 
about the knee revealed a small fissure, which was distinctly 
felt in the edge of the tendon near the patella, quite sharp, and 
evidently showing that the tendinous fibres had been ruptured 
at that point. The patient was advised to try perfect rest for 
the limb, to have a ham-splint applied, continuing the treatment 
for at least three months. This was faithfully done for between 
three and four months, and resulted in a perfect cure. 

As I now state this case from recollection, I am unable to 
give with distinctness all the incidents in it ; but the fact of the 
rupture and the result of the treatment are undoubted. 



HYDROPHOBIA. 

Case CCCLV. — Hydrophobia. Death. — The following 
account was principally written from data furnished by Dr. J. 
Stearns, then house-surgeon to the Massachusetts General Hos- 
pital, who took much interest in investigating the facts of the 
case. The patient was a male child, by name Patrick Murphy, 
three years of age, living in Boston, and was brought into the 
Hospital on June 25, 1859. 

Five weeks before, he was bitten by a dog six or eight months 
old. The animal was not thought to be rabid by the bystand- 
ers ; although, on the same day, he had "snapped at and 
slightly bitten " a man, as was thought, from playfulness. The 
little boy had a cracker in his hand, which the dog attempted to 
seize, taking into his mouth with it the whole of the right hand, 
and inflictino" a wound on each side of the wrist. The wound, 
on the anterior surface, was from half to two-thirds of an inch 
in length ; that on the opposite side was like the mark from a 
simple puncture. The wounds were treated by a surgeon, who 
cauterized them not long after the injury, and ordered a poultice. 
There was no further treatment used. They were very sore, for 
a time, particularly tlie one in front ; but the child continued as 
well as usual in his general health, and nothing remarkable oc- 
curred till a week before his admission to the Hospital. 

At this time, the mother's attention was drawn to the child, 



HYDROPHOBIA. 585 

by what she called a " dulness " coming over him, followed by 
a "silliness and listlessness." Four days before liis entrance to 
the Hospital was the first onset of the paroxysms, which were 
described as having been quite formidable ; they were especially 
violent when water was brought near him, so that the mother 
was obliored to (Ave up washino: the child. He manifested a 
desire to take food and drink from his mother, though, on at- 
tempting to swallow, he was quite unable to effect it. For this 
reason, he took scarcely any nourishment for four days before' 
he was brought into the Hospital. The preceding facts were 
principally obtained from the parents of the child. 

On his entrance into the house, he was in a highly excited 
condition, tossing his head, and throwing about his limbs in 
every direction. He spit violently, or attempted to do so, as 
if his mouth was full of feathers ; occasionally crying out or 
snapping at those about him, saying that he wished to bite 
them, and they must get out of his way. His eyes were very 
bright, his face pale, and there was a lividity about the eyelids, 
and generally over the whole surface, with a quivering of the 
lips and muscles of the face, and constant tremor of the whole 
body. On taking a dose of morphine, he was quieted, and the 
nurse prevailed on him to swallow some milk from a mug. 
After a time, he drank a whole mugful, and ate a small piece 
of cake. His manner of taking the milk was not as if he had 
any aversion to it, but from apparent consciousness of the 
effort necessary to swallow. He clutched violently at the mug, 
with eyeballs starting out, and the whole frame undergoing the 
greatest agitation. The effort of swallowing was attended with 
a sense of suffocation, and the corners of the mouth were 
strongly retracted. He exhibited the same symptoms on taking 
cake ; and, from his great desire for both, appeared to be suffer- 
ing much from hunger. A viscid discharge took place from the 
mouth. The urine was passed in great abundance through 
the afternoon and evening. 

He gradually became quite calm, through the great attentions 
of the nurse, who seemed to inspire him with confidence, and 
went to bed with him in her arms, in spite of the remonstrances 
of those about her. He talked incessantly and incoherently, 

74 



586 MISCELLANEOUS CASES. 

though at times he could be understood. He seemed to appre- 
ciate much the kindness of the nurse, and told her he should 
bite her; but, when she put out her arm to him, he kissed and 
stroked it. He had several paroxysms after his entrance, 
with intervals of comparative quiet ; the attacks being only of 
short duration, lasting about five minutes each. He became 
weaker as the night advanced, and, at half past 3, A.M., died in 
one of the convulsive attacks. 

No examination of the body could be obtained. 

Dr. Stearns, at my request, visited the house at which the 
child had resided, for the purpose of obtaining some more facts 
in regard to the case, but did not elicit any thing of importance 
beyond the preceding. He saw the wife of the man who was 
bitten on the same day with the little boy : the bite was said to 
be a very slight one, on the joint of one finger, and no blood 
came from it. The man promised to be at the Hospital on the 
following day for me to examine it, but, for some reason, did 
not appear. The dog was drowned, and Dr. Stearns could 
get no further history of it. A superstition existed with them, 
— of which they informed him, — that, if the dog could have 
been killed by one of the family, the patient would have es- 
caped ; also, that, if the liver of the dog could have been 
applied to the wound, the effect would have been equally 
efficient, which, of course, naturally implied the death of the 
doo^. 

In connection with this case of hydrophobia, I would remark, 
that, about fifteen or twenty years since, I proposed, at a meet- 
ing of a society, for the purpose of obtaining information, the 
question whether any case of hydrophobia had ever occurred in 
Boston, or whether there was any tradition of one in the New- 
England States ; but no answer was elicited in the affirma- 
tive. 

The first case reported in Boston appears to be that of Dr. 
Coale, in October, 1848, which was followed, shortly afterward, 
by that of Dr. Curtis, in Lowell, supposed to have been caused 
by the same dog, which had escaped from Boston, and made his 
way to the latter city. This was followed by other cases in 
various directions, running through a course of two or three 



HYDROPHOBIA. 587 

years, during which time I saw, in consultation in Brookline, a 
patient of Dr. AVild, and the case of a child brought into the 
Hospital within twelve hours after having been bitten, where 
the parts were freely cauterized at the time, and, within twenty- 
four hours from the time of the accident, cut out by Dr. Cabot. 
This patient returned home within four weeks, apparently per- 
fectly well ; but, by the expiration of another week, the disease 
appeared, and she was returned to the Hospital, with all the 
symptoms similar to those detailed above. 

All these patients died, after three or four days' illness ; the 
attack comino^ on in an averas^e of about five weeks from the 
receipt of the injury. 

After that period, the contagion, if it may be so called, or 
inoculation, seemed to have exhausted itself; and but few cases 
were recorded until 1859, when rumors began to be heard of 
its re-appearance. I have constantly had persons call to consult 
me with very severe bites from dogs ; but, not finding from them 
that the animals had shown any signs of rabies, I have not 
thought it warrantable to apply so severe a remedy as cauteriza- 
tion or excision to an accident so common. When rabies is 
actually present among the canine race, I should feel myself 
called upon to make a thorough application of the nitrate of 
silver to the wound, as recommended by Mr. Youatt, who con- 
sidered this remedy as almost infallible, if applied immediately ; 
and who, from his liability to be bitten, always carried a piece 
of caustic in his pocket, and had many times made use of it with 
effect on his own person ; or, if circumstances required, free 
excision should be made of the injured part. 

The following remarks of Mr. Youatt are of so much value, 
that I have extracted them at some length : — 

" The wound should be thoroughly washed and cleansed as soon as 
possible after the bite is inHicted ; no sucking of the parts, as is ad- 
vised by many, for the purpose of extracting the poison, as the pres- 
ence of a small abrasion of the lips or interior of the mouth would, 
most assuredly, subject the parts to inoculation. If the wound be 
ragged, the edges may be taken off with a pair of sharp scissors : the 
wound must then be thoroughly cauterized with nitrate of silver (lunar 
caustic), being sure to introduce the caustic into the very depths of the 



588 MISCELLANEOUS CASES. 

wound, so that it will reach every particle of poison that may have 
insinuated itself into the flesh. If the wound is too small to admit of 
the stick of caustic, it may be enlarged hy the knife ; taking care, how- 
ever, not to carry the poison into the fresh cut, which can be avoided by 
wiping the knife at each incision. Should the wound be made on any 
of the limbs, a bandage may be placed around it during (he application 
of these remedies, the more effectually to prevent the absorption of the 
veins. Nitrate of silver is a most powerful neutralizer of specific 
poisons, and the affected parts will soon come away with the slough ; no 
dressings being necessary, except perhaps olive oil, if there should be 
much inflammation of the parts. If the above plan be pursued, the 
patient need be under no apprehension as to the result, but make his 
mind perfectly easy on the point." 

A question has been frequently asked, whether these symp- 
toms might not be of a tetanic character, from the irritation of 
the wound. There has not been the slightest appearance of tris- 
mus, or locked-jaw, in any of the cases I have seen ; and the 
lapse of time from the receipt of the wound has been too 
lonof to be attributed to such a cause, the wounds havinsf 
healed, and, for the most part, having shown little signs of 
irritation. 

When writing this, I had a case of trismus, or locked-jaw, at 
the Hospital, which, although not severe, afforded an oppor- 
tunity of comparing this rare disease with hydrophobia. The 
patient was a woman, 45 years of age, in quite good health, 
upon whom a large plank fell, producing a compound fracture, 
and dislocation of the ankle-joint. I saw^ her about half an 
hour after the receipt of the injury : the lower extremity of 
the tibia projected through a large wound at the ankle-joint, 
the internal malleolus being broken off, and left in the wound. 
This I removed with a knife, so as to allow the dislocated bone 
to be restored to its proper place, with the hope, in the first 
view of the case, of saving the limb. On further examination, 
however, when the restoration of the bone allowed of a more 
full investigation of the joint, I found the injury of the tibia 
to be complicated w^ith a comminuted fracture of the fibula, some 
pieces of which lay loose in the joint. Another fracture of the 
fibula also existed, about half-way up the limb. Amputation 



, HYDEOPHOBIA. 589 

of the leg was, therefore, resorted to by the double flap, just 
above the upper fracture, in what appeared to be sound parts. 

Although every thing seemed to be favorable for union by 
the first intention, yet the wound partially suppurated, and took 
on a sloughy appearance ; the vital powers of the tissues having 
probably been injured by the blow, although this, at the time, 
was not apparent. The patient, however, complained of little 
or no pain, but seemed to be quite comfortable and in good 
spirits, though with little appetite : she had no fever, and no 
other symptoms of constitutional irritation. 

On June 30th, Avhen I visited her in the morning, she told 
me that her jaws were stiff, and she could only open them 
about a quarter of an inch, by taking hold of them Avith her 
hands. She said that she had felt some soreness in her jaws for 
about four days, but had not thought it of sufficient import- 
ance to mention. I suspected the nature of the disease, and 
requested Dr. Stearns to keep a close watch upon her, and 
inform me if any thing unusual occurred : I also encouraged 
her to take a more stimulating diet. She herself was not 
advised of our suspicions. 

In the afternoon, she w^as suddenly taken with slight tetanic 
spasms, great difficulty of breathing, and coldness of the ex- 
tremities : stimulants were administered, hot applications and 
other external remedies used; and, when I saw her about 6, 
P.M., she was in a very comfortable condition. Her jaws, at 
this time, had to be pried open to introduce any thing. I 
ordered a drachm of the solution of the sulphate of morphia 
to be administered every three or four hours, and as much brandy 
to be given as she was disposed to take. 

She passed a very quiet night under the treatment directed, 
and, on the following day, pronounced herself much relieved : 
the stump was suppurating freely, and gave her no pain. 

The mental condition of this patient and of the one with hy- 
drophobia, it will be perceived, were strikingly diffisrent. The 
former was perfectly calm and collected, the pulse not much 
affected, being rather below than above the natural standard : 
the latter semi-delirious, agitated, and violent ; the pulse very 
rapid. To a person who has seen the two diseases, a mistake in 
the diagnosis is not easy. 



590 MISCELLANEOUS CASES. 



EXTRACTION OF NEEDLES. 

The extraction of needles which have penetrated different 
parts of the body is not an unimportant part of surgery. As 
a rule, it is better never to attempt an operation unless the 
needle can be distinctly felt. Even then, after the first incisions, 
if it is not immediately exposed, the traces of it are apt to be 
lost, and the search tedious. Where the operation fails to dis- 
close it, by the application of a poultice bringing the wound 
into a suppurating state, the discolored needle, in the course 
of a few days, often makes its appearance ; and I do not re- 
member, in my own practice, any instance of injury to the 
patient from delay under the above circumstances, whereas great 
harm may be done by an unavailing search among delicate and 
sensitive textures ; for instance, the palm of the hand, the sole 
of the foot. I propose to give a few cases of the results of 
needles penetrating the knee-joint, a number of which have 
come under my observation ; these being, on the whole, the 
most embarrassing of any of this class of cases that we have to 
deal with, and the knee-joint being more exposed than any of 
the joints to this kind of injury. It will be observed, that, in 
three out of the four cases given below, the needle broke oif 
in the joint, after having been fixed in the bone. 

Case CCCLYI. — Needle 'penetrating the Knee-joint, 
Remained fixed between Condyles. — Feb. 13, 1854, a child 
of scrofulous habit, five or six years old, while kneeling on 
the floor, had a needle larger than the ordinary darning-needle 
penetrate, and break oflf in the knee-joint. Being called to see 
this child, in consultation, I found that a small aperture could 
be distinguished below and to the inside of the patella. The leg 
was flexed on the thigh, and fixed in that position so that it could 
not be extended. The needle seemed to have penetrated be- 
tween the condyles of the femur, to have become fixed there, 
and to be broken off in the joint, as nothing could be felt of 
it externally. I advised that a dissection should be made as far 
as the capsule, but to abstain from going further unless the 
needle could then be detected. 



EXTRACTION OF NEEDLES. 591 

This was done, but nothing found. The question then arose, 
whether the limb should be left in the position in which it was 
fixed. I advised strong flexion and extension to be made, so 
that, in case the body were lodged in the way supposed, it 
might either be dislodged, or else plough up for itself a cavity 
in the cartilage of the head of the tibia. By these measures, 
the motions of the limb were restored. The child was kept 
perfectly quiet for a few weeks, until all inflammatory symptoms 
had subsided; after which, he walked about without incon- 
venience. 

This patient died of phthisis some years after the accident ; 
and, on examination of the knee-joint, the following was the 
appearance : The needle, as had been supposed, was firmly 
lodged between the condyles of the femur. It was somewhat 
corroded ; and, from the motions of the joint, it had worn and 
maintained for itself a passage, so as not to interfere with flex- 
ion or extension. The joint itself was otherwise healthy. 

Case CCCLVII. — I^eedle penetrating Knee-joint. Fun- 
gous Growth from Wound. Recovery. — A child six years 
old ran a needle into the knee-joint, in the summer of 1853. 
It was immediately withdrawn ; and the child, not suifering 
any pain, was allowed to use the limb. A few days after, 
severe inflammation came on in the wound, and a fungus shot 
out. At this period, I was called to see the patient. The 
joint was found to be in a very tender and inflamed condition. 
On flexion, a quantity of pus ran from the wound, which was 
surrounded by a fungus of the size of a five-cent piece. Entire 
rest, with a splint, was enjoined, and the fungus was touched 
with caustic ; causing at each application an increase of in- 
flammatory trouble. After four or five weeks of treatment, 
the case finally terminated favorably. The needle had entered 
just on the inner side of the ligament of the patella. 

Case CCCLVIII. — Needle hrolcen off in Joint. Fixed 
in Bone. Removal hy Operation. — This instance was ob- 
served in a child of five years. Kneeling down on the floor in 
front of a bureau, to get something from underneath it, a needle. 



592 MISCELLANEOUS CASES. 

which had been engaged in the carpet, ran into the joint, and 
broke off. When seen by me with her physician, Dr. Ball, her 
limb was painful on motion, somewhat swollen, and she was 
miable to walk. By making strong flexion, a hard substance 
could be felt below the patella, on the inside of the joint, giving 
to the touch the sensation of some large body like a nail. 

The patient being etherized, a dissection was made through 
the skin and fat, until what appeared to be the capsule of the 
joint was reached. Within this, the foreign substance was 
felt, firmly embedded. The nails of the two forefingers were 
pressed against it on each side, causing it to project through the 
capsule, when it was seized by the forceps. It was now found 
quite difficult to extract ; and this was only done after a number 
of efforts, and by working it laterally, thus disengaging it from 
the bone. A splint was dh-ected, with applications of cold 
water, and care in diet ; her physician promising to give informa- 
tion if any symptoms requiring attention should present them- 
selves. 

The patient did well. 

Case CCCLIX. — Needle broken off in Knee-joint and 
fixed in Bone. Extraction. In January, 1867, I was called 
in the evening to see a young lady, 15 years of age, who, three 
hours before, while kneeling on the carpet with a child in her 
arms, felt something penetrate her knee. She immediately 
examined, and withdrew through her clothes two-thirds of a 
common-sized needle. She was able to walk up stairs, though 
somewhat lame. When I saw her, with her physician, we 
detected a small puncture, surrounded by an ecchymosis below 
and on the inner side of the patella. On a careful examination 
Avith the finger, a hard substance could be detected like the por- 
tion of a needle, which varied its position according to the 
motions of the joint. It could not, however, be made promi- 
nent. The probability was, that it had penetrated the bone, and 
had broken off" inside the joint. I determined to cut down as 
far as the capsule, and explore. This was done by a very care- 
ful dissection, occasional pauses being made to allow the bleed- 
ing to cease. The capsule, covered by a slight cellular layer, 



INJURIES OF THE OS COCCYGIS. 593 

being arrived at, the substance, which could easily be felt with 
the limb extended before the incision, now almost completely 
disappeared. The limb was then forcibly bent, when the needle 
at once was felt pressing against the capsule, and apparently 
fixed in the under part of the patella. The wound being held 
widely open, and every thing kept steady, with the handle of 
the knife on one side, and the nail of the thumb on the other, 
the needle was made to project through the capsule, and could 
be seen through the areolar tissue over it. A touch or two of 
the knife now exposed it; and, being seized with the forceps, 
with a little force it was diseniijas^ed from the bone. It was 
about half an inch long, and had already become blackened. 

The wound was at once closed by a suture and adhesive 
plaster, and the limb confined in a straight position, in a splint, 
with an injunction not to flex it for a week. I saw her on the 
following day; and she was quite free from any pain, swelling, 
or sensibility of the joint, and has since done well. 



INJURIES OF THE OS COCCYGIS. 

I have met with quite a number of instances of this kind, 
where the lower part of the os coccygis has been injured ; all of 
them occurring to females from slipping while descending the 
staircase, or stepping suddenly out of doors on a step covered 
with ice, and receiving various concussions in sliding from one 
stair to another. The severe and long-continued symptoms 
arising from this injury are not easily explained. Scarcely an 
instance can be said to have resulted in perfect recovery ; and 
many of them have caused severe local symptoms for some 
months and even years afterwards. The symptoms do not seem 
to be easily explained, either by supposing them to be caused 
by a concussion of the spinal marrow, or by a local lesion of 
the nerves of this part : although the region is very fully sup- 
plied by nervous filaments. They seem to resemble more closely 
those acute pains which attend periosteal inflammation. The 
eflect of this injury I propose to illustrate by a number of 
cases. 

75 



594 MISCELLANEOUS CASES. 

Case CCCLX. — Injury of the Coccyx. — A lady slipped 
as she was coming down stairs, and struck violently on the 
coccyx. She descended two or three stairs, striking on each 
of them as she fell. The pain in the part, after the injury, w^as 
of the most severe character : the w^hole system seemed to sym- 
pathize with it, and there was considerable numbness in the 
upper and lower extremities. 

The constitutional symptoms very gradually subsided ; but the 
pain and inability to sit upon the part lasted more than a year, 
and the sensitiveness of it continued for ten years after the acci- 
dent. At the time, on examination, no fracture could be 
detected ; but, on account of the sensitiveness to the slightest 
touch, the investigation was necessarily superficial. 

Case CCCLXI. — Injury of the Coccyx, — A lady who, 
for some years, had been in delicate health, slipped as she 
was descending the stairs, and went from the top to the bottom, 
striking successively the lower part of the back on each stair. 
She w^as taken up in an almost insensible condition. As the 
first shock of the accident subsided, the most violent sympathetic 
nervous symptoms supervened, attended with severe pain in 
the coccyx. The head was in a state of great congestion and 
confusion, the hearing and eyesight exquisitely sensitive, the 
arms and legs spasmodically contracted. 

Being out of town, this lady was attended by one or two dis- 
tinguished physicians, who came to her from a distance. The 
coccyx being examined, a distinct displacement of the bones 
was distinguished, and by proper manipulations adjusted. In 
this condition she remained two or three months, unable to 
be removed to the city, and requiring constant application of 
remedies to relieve pain and sustain life. She was finally 
brought to Boston, and came under my care. 

When she first arrived, I made an examination, and discovered 
a distinct swelling between the first and second bones of the 
coccyx, feeling as if ossific matter had been thrown out there. 
At the end of four months, these appearances had subsided. 
During the interval, the patient had been confined to a bed or 
sofa, and, notwithstanding every contrivance that ingenuity could 



INJURIES OF THE OS COCCYGIS. ^ 595 

suggest, was unable to bear any pressure upon the injured 
part. Air-cushions, with apertures in them, had been tried, 
but without effect ; the mere tightening of the skin around pro- 
ducing suffering not to be supported. The patient was now able 
to walk about the room a little with support, and after a time 
was taken down stairs in the arms of attendants, put into the 
carriage, and driven out, supported in the horizontal position. 
She did not recover from the immediate effects of the accident 
for one or two years, and now, at the end of eight years, is not 
able to ascend stairs without suffering. 

Case CCCLXII. — Injury of the Coccyx. — An unmar- 
ried female, 30 years of age, was brought into the Massachu- 
setts General Hospital in the spring of 1858, having fallen 
while going down the cellar-stairs, striking violently on the 
coccyx, and injuring one of the ribs. She complained very 
little of the latter injury, although one of them seemed to be 
fractured, but made the most violent exclamations in regard to 
the suffering in the lower part of the sacrum. There was an 
inability to move the lower extremities, but no want of sensi- 
bility in them. Xo fracture or displacement of the coccygeal 
bones could be detected. Leeches, fomentations, the internal 
administration of opium, were resorted to. The only relief, 
however, which she obtained, was from the local application of 
laudanum, or poultices sprinkled over with ten grains of opium. 
It was two or three weeks before she began to obtain decided 
relief, and about six before she was able to leave the Hospital. 

Case CCCLXIII. — Fracture of the Coccyx, — While 
making a visit at the Hospital with Dr. Cabot, in February, 
1859, he pointed out to me a patient he had just success- 
fully treated for vesico-vaginal fistula. I observed that she 
sat leaning forward in a very awkward position. Dr. Cabot 
said that the position was not owing to her present difficulty, 
but to an injury she had received some years before in going 
down the cellar-stairs, when she slipped upon something left in 
the way. The consequence was a fall, in which she struck 
on the lower part of the back. The coccyx was fractured and 



596 MISCELLANEOUS CASES. 

displaced, and remained so, as was verified by an examination 
made by himself. At the time, she was confined about five 
weeks, with very severe symptoms, and had never ceased to 
suflfer in the part up to that time. 

Case CCCLXIV. — Repeated Injuries of the Coccijx. — 
In March, 1859, I was called to a married lady who had fallen 
the day before on the ice, striking her back. Part of the blow 
was received upon the coccyx. The injury produced considera- 
ble lameness, and, for some days, almost inability to bend the 
back or make any lateral motions. 

This patient twice before had a similar injury : once, when a 
child, from the eflfect of which she never recovered ; and the 
second time about fifteen years after, when she was under my 
care for the same injury, at which time she was confined to her 
bed for a number of days, requiring the persistent application of 
narcotics. 

Case CCCLXV. — Injury of the Os Coccygis. — May, 
1859, a young lady, 19 years of age, was brought to me with 
an injury of the coccyx. Three years before, while sliding on 
the ice, she fell, and received a severe blow on the lower part 
of the spinal column. The pain and tenderness confined her for 
two or three days, and she was unable afterwards to bear the 
least pressure on the part, while there was a constant sense 
of uneasiness in it. 

About a year before, a swelling commenced there, and slowly 
increased till it became of the size of a walnut, but with no 
inflammatory appearances about it. This was punctured in 
April, 1859, by her physician ; and, as he stated, a curdy mat- 
ter discharged from it. After that, a serous fluid continued to 
flow ; the opening remaining fistulous, with an inflamed elevation 
of nearly half an inch above the surrounding tissues. The dis- 
charge caused considerable irritation between the nates and in 
the vicinity. 

Having examined the disease with a probe, and not discover- 
ing any carious bone, I advised that the patient should be ether- 
ized on the following day, and the tumor freely incised. This 



FRACTURE OF BASE OF SKULL. 597 

being done, and the cavity fully exposed by a free incision, a 
finger was introduced, and the end of the coccyx felt, but not 
denuded. The interior of the cavity, being now exposed to the 
light, presented that white, silvery, epithelial aspect observed 
in the sacs of some encysted tumors. The whole of this sac 
was carefully dissected out, and the cavity stuffed with scraped 
lint. 

On the second day after the operation, a poultice w^as applied, 
which freed the wound from the adherent lint. The wound was 
afterwards dressed simply, and the patient allow^ed to get up 
and move about. She recovered entirely. 

Dr. Simpson, of Edinburgh, has described this affection in 
his usual clear manner; and, in some obstinate cases, after 
having tried all remedies in vain, proposed, and practised wdth 
success, the girdling of the coccyx by subcutaneous section, 
just above the diseased part, so as to cut off all nervous com- 
munication with it. 



FRACTURE OF BASE OF SKULL. 

Case CCCLXYI. — Fracture of the Base of the Skull. 
Recovery. — A man was brought into the Hospital, June 2, 
1866, in an apparently dying state, who, two days before, had 
fallen from an attic window, out of which he was leaning on 
account, as he afterwards said, of an asthmatic affection. He 
lost his balance, and fell twenty or thirty feet, striking on his 
head. When I saw him, he was lying on his back in a par- 
tially comatose state, and, when roused, answered reluctantly by 
signs. His right eye was ecchymosed, pupil fully dilated, and 
not at all stimulated by the light. He had had a bloody dis- 
charge from both ears ; the marks of it on the right side still 
remaining. His pulse was 120, soft, regular, and moderately 
full. 

An examination of the cranium being made, no fracture could 
be detected. There was very great tenderness at the upper part 
of the spine, where it joined the head. Contusions w^ere found 
over various parts of the body. 

The patient remained in a very low condition for about four- 



598 MISCELLANEOUS CASES. 

teen days, and with all the symptoms of fracture of the base of 
the skull. He was then attacked with a severe diarrhoea, which 
none of the remedies used seemed to have any eiFect upon, and 
while it reduced his strength, seemed to improve his intelli- 
gence. Under it, in the course of ten days, the cerebral symp- 
toms disappeared ; and he began to recover the sensibility of 
the right eye so as to distinguish light from darkness, and at 
times could see large objects before him. After arriving at the 
very lowest state of muscular debility, he began to revive, and 
was finally sent to one of the public institutions ; the symptoms 
caused by his original injury being in a great measure relieved 
after about four weeks of treatment. 

This case is related as one in which, from the way the injury 
occurred, and the subsequent symptoms, death was thought to 
be inevitable by all the surgeons who saw him. The cerebral 
symptoms were apparently relieved by the supervention of diar- 
rhoea. 

Case CCCLXVII. — Resuscitation of a Young Lady after 
Long Submersion. — There has been considerable difference of 
opinion expressed as to the length of time required for death 
to take place by drowning. Two or three minutes' submersion 
is generally considered sufficient to destroy life. Cases, how- 
ever, have been adduced, of persons who have been six, fifteen, 
or even thirty minutes under water, and yet have been restored. 
The following case occurred at the dreadful accident at Norwalk, 
Conn., where, from the train of cars running off the bridge into 
the channel of the river, from forty to fifty persons lost their 
lives. In this case, nearly twenty minutes elapsed before at- 
tempts at resuscitation were commenced : and, at the very low- 
est computation, ten minutes must have passed before the patient 
was taken from the water; i.e., time enough for a boat to put 
out into the middle of the stream, an aperture to be cut with an 
axe in the side of the car, her mother to be removed, who had 
her head above water, and still kept hold of the young lady, who 
was fixed in the seats beneath the water. After being taken 
from the car, she was transported to the shore in a boat, and 
thence an eighth of a mile to the shed where I first saw her. 



RESUSCITATION AFTER DROWNING. 599 

At this time, all the physical appearances of death were 
present. The body was cold, the mouth and nose covered with 
froth, the face swollen and livid, the pulse could not be felt, and 
respiration had entirely ceased. After clearing away the froth 
from the mouth and nostrils, I had the body inverted, so as to 
drain the water as much as possible from the air-passages. The 
motions of respiration were then imitated by raising and depress- 
ing the ribs. At the same time, the finger was passed down the 
throat, and the epiglottis lifted, to enable the air to enter the 
cavity of the chest. By following up this process, aided by 
frictions over the whole body, I finally discovered some action in 
the muscles of the throat; and, on perseverance, a slight gasp 
at length showed that life was not extinct. Respiration and 
restoration of the pulse were not established till after long per- 
sistence in the process described. Meanwhile, by sending to the 
village, a blanket was obtained, in which she was wrapped, and 
her Avet clothes removed. Having procured some brandy, her 
mouth was stimulated with it ; and subsequently a little was 
poured down the throat, when I thought the power of swallow- 
ing was restored. Constant and long-continued action was re- 
quired, before the circulation and respiration were regularly 
performed. In about two hours, or as soon as I thought it 
safe, she was wrapped up, and conveyed to the house of the 
hospitable people in the vicinity, who did so much on that day 
to succor the wounded. She shortly after became delirious, in 
which condition she remained for a part of the day. For a 
week she was seriously ill ; but I saw her about a month after- 
wards completely recovered, and entirely unconscious of the 
events which had transpired during that dreadful day. 

Out of fifty persons drowned, she was the only one recovered. 
The shed in Avhich I was, was filled with bodies taken from the 
water; and, as they were brought in, I instructed and encour- 
aged the bystanders to go through the same manoeuvres that I 
was practising in the present case. Partly from want of 
persistence in them, but more probably from the attempts com- 
ing too late, nothing was effected. There were many distin- 
guished physicians in the train, some of whom were destroyed 
either by drowning, or from concussion received by the falling 



600 MISCELLANEOUS CASES. 

cars ; and those who escaped were engaged in the town of Nor- 
walk, at a distance, doing efficient work among the wounded, — 
setting fractured bones, sewing up wounds, and giving other 
assistance. 

Case CCCLXYIII. — Liduration of the Cellular Tissue. 
— This disease is a very common one in the French hospitals, 
and a very fatal one ; more than two-thirds of those who are 
attacked with it dying. By examinations after death, yel- 
lowish or greenish sero-albuminous fluid is found effused into 
the cellular membrane. The remote cause is uncertain. It has 
been frequently attributed to the imperfect filling of the lungs 
with air at birth. 

In this country and in England the affection is a very rare 
one, and I have seen but few cases of it. My friend, Profes- 
sor D. H. Storer, — whose experience on the subject is second 
to that of no one in New England, and whose valuable advice, 
I take this opportunity of saying, I have availed myself of in 
many cases related in this work, — informs me that he has very 
seldom met with it in his practice. The following is an in- 
stance : — 

In February, 1847, I was requested to see a child six weeks 
old, and received the following history of it : When a week old, 
it was accidentally discovered that the cellular membrane of the 
thighs and legs was as hard as marble, and that this had gradu- 
ally extended up on the body ; the part at which the hardness 
terminated being so perfectly distinct that it could be marked 
by a line drawn around the body. I directed frictions to be 
made over the indurated part with warm sweet oil ; and, in the 
event of this failing, the use, to a limited extent, and with 
proper precautions, of mercurial ointment. 

Under this treatment, the hardness began gradually to be dis- 
pelled ; and, at the end of six weeks, it had quite disappeared 
from every part, with the exception of a few lumps in the pop- 
liteal space. 

Case CCCLXIX. — Ivory Penholder, four inches long, 
removed from Bladder. — In February, 1844, 1 was requested 



WRY NECK. 601 

by a physician to see a boy 14 years old, who, two days before, 
while engaged in passing an ivory pen-handle into his urethra, 
had it slip from his grasp, and carried back into the bladder. 
After the accident, his water dribbled away from him, and was 
occasionally tinged with blood. 

Wishing to conceal the ftict of its introduction, he had made 
an incision into the perlnaium with a penknife, for the purpose 
of extracting it, thinking he felt it at that point. 

On examination by the rectum, the foreign body could be 
distinguished lying across the bladder, one end of it just 
eno^ao'ed in the neck of that oro^an, from which it had been 
prevented from entering entirely by the irritation caused by it 
producing a contraction of the cavity to half its natural size. 

Cooper's forceps, for extracting small calculi, were now in- 
troduced into the urethra; and, on reaching the foreign body, 
opened and manipulated, with the expectation of engaging it in 
its grasp. After some ineffectual manoeuvres, this was finally 
effected ; and the penholder, whose farther extremity was lifted 
up in the bladder, was seized at an obtuse angle. By a little 
traction, and aided by the finger in the rectum, it made a spring- 
like motion on the forceps, and came into a straight line with 
it, and was thus withdrawn. 

All the symptoms were at once relieved. 

Dr. Paul F. Eve, in his collection of "Remarkable Cases in 
Surgery," has given a number of instances in which foreign 
bodies have been removed from the bladder in this way. 

WRY NECK. 

Case CCCLXX. — Division of the Sterno-mastoid Mus- 
cle for Wry JSfech. — I was requested, in 1841, to see a boy 
16 years old, affected with wry neck, and received the following 
history of his case : — ■ 

When four years of age, he fell from the top of a staircase 
to the bottom. No wound was to be discovered on any part of 
the body : he complained, however, of a pain in the left side 
of the neck. Shortly after the accident, it was found that the 
head inclined to the left, and that the muscles of that side were 

76 



602 MISCELLANEOUS CASES. 

in an unnatural state of tension. This distortion gradually in- 
creased, until it attained the appearance which it presented at 
the time I saw him, twelve years after the accident. At this 
period, he was suffering from frequent attacks of headache, and 
from an almost constant and severe pain in the left side of the 
neck. He was rather short for his age, and the distortion aided 
much to diminish his natural height. 

On viewing him in front, the following were the appearances 
observed : 1st, The head was drawn down to the left side, 
the ear usually resting on the left shoulder, although he had the 
power of raising it a little from that position ; 2d, This inclina- 
tion was accompanied by a rotation of the head, so that the face 
reocarded the rio^ht shoulder. 

Observed from behind, there was a deep sulcus on the left side 
of the neck, with a corresponding projection on the right side, 
made by the transverse processes of the cervical vertebrae. A 
curve had taken place both in the cervical and in the lumbar por- 
tions of the spinal column. The left shoulder was higher than 
the right. The left side of the chest was projected, and there 
was a considerable depression of the ribs on the opposite side. 
On examination of the vertebrae, proceeding upward, the spin- 
ous processes of the cervical portion could be distinguished until 
the third vertebra was arrived at : here the line of the column 
was lost, being concealed under a large mass of muscle ; with 
great care, the spinous process of the second cervical vertebra 
was discovered, having performed a rotation of nearly the 
quarter of a circle on its axis. The sterno-mastoid muscle of 
the left side, on being examined, was found to be very strongly 
retracted, as well as the deep-seated muscles of the neck ; the 
scaleni particularly could be made out in an unnatural state of 
rigidity. The former, however, appeared to be the chief 
obstacle to the endeavors for bringing the head to an upright 
position. 

In addition to these changes, the face had undergone a re- 
markable alteration, worthy of notice. The whole left side of 
the face was more or less atrophied, and each of its component 
parts was much smaller than those of the other side : the left 
eye was much smaller than the right, which was raised up, and 



WKY NECK. 603 

on a level higher than its fellow ; and this appearance was not 
owing to the inclined position of the head alone, as was more 
distinctly verified when the face was brought into its natural 
position after the operation. 

The health of the patient was not good ; and in addition to 
the mortification of being afflicted with so severe a deformity, the 
pain at the spot where the curvature was most extreme was at 
times excessively severe. He slept usually on his right side, 
sometimes on his back, but never by any chance on the left 
side. 

It having been ascertained, so far as was practicable, that the 
chief obstacle to the restoration of the head existed in the un- 
natural state of the sterno-mastoid muscle, it was determined 
to divide it at its sternal insertion ; the retraction, according to 
Gudrin, who is considered the best authority on this point of 
surgery, generally existing in this portion of the muscle. 

The operation was performed as follows : The head being 
supported, and carried a little forward, so as to project the 
muscle outward from the subjacent parts, the patient was 
directed to make strons^ efforts to exao^orerate the existing^ rota- 
tion, so as to produce as great a tension of the muscle as pos- 
sible. A puncture was now made with a lancet through the 
skin, about six lines above the clavicle, between the sternal and 
clavicular portions of the muscle. The narrow, blunt-headed 
knife of Bouvier was next introduced, its flat side towards 
the muscular fibre, carried behind the sternal head, its edge 
towards the muscle, and the section completed b}^ a slight 
sawing motion. The effects of this operation were at once 
manifested by a distinct crackling sound, by a separation of the 
divided parts, and by the partial restoration of the head to its 
natural position, also by the possibility of rotation in every 
direction. The wound on the neck was covered with a piece of 
court-plaster, a cap placed on the head, to the back of which, 
opposite the right mastoid process, a strap was attached, and, 
being drawn tight, was secured over. the breast of the same 
side. 

On the following day, he was quite comfortable : he had slept 
well, lying on his left side, which he had been unable to do 



604 MISCELLANEOUS CASES. 

before the operation; the pain in his neck had entirely left 
him. The plaster covering the wound was removed at the end 
of forty-eight hours, entire cicatrization having taken place. 
The patient was then directed to wear a stock on the neck, and 
to make strong and constant efforts to rotate the head : he was 
also placed on an inclined plane for three or four hours daily, 
the head secured by a bandage carried under the chin and 
attached to the upper part of the board. 

In the course of a fortnight, a very great improvement was 
perceptible : the head, however, had not yet regained its proper 
position, but was still inclined to the left. The divided muscle 
had united ; a firm and almost cartilaginous substance being 
apparent at the point of union. The clavicular portion of the 
muscle had become much more prominent since the division of 
its sternal attachment, and felt round and corded, presenting 
an obvious obstacle to the adjustment of the head. It was 
therefore thought advisable that the division of this part of the 
muscle should be effected ; and, in order to derive the full 
advantage from it, the operation was performed in the following 
manner : — 

The head being supported and the muscle sufficiently relaxed, 
the body of the sterno-mastoid, just above its division into ster- 
nal and clavicular heads, could be readily seized between the 
thumb and forefinger, and completely isolated from the deep- 
seated parts. An appropriate knife was now carried behind the 
muscle, until it could be felt by the finger under the skin on 
the opposite side ; and, the patient being directed to place the 
muscle in strong contraction, the section was completed without 
difficulty. 

The second operation was not follov/ed by any inflammation, 
the wound being quite healed at the end of forty-eight hours ; 
and, by persisting in the treatment before directed, the head was 
very shortly restored to its normal position. Nine months after 
the operation, I made the following observations of his appear- 
ance : — 

To a person regarding him in front, a slight cant of the head 
is observable to the right side, evidently owing to the constant 
and determined efforts of the patient to overcome his deformity 



WRY NECK. 605 

by carrying the head in an opposite direction. The face still 
presents the alteration already pointed out; viz., an atrophy of 
the whole of the affected side. The eye of the left side is much 
less prominent, the lid more closed, and the level of it lower 
than its fellow : the whole osseous, cellular, and muscular system 
partake in this alteration, or want of development. 

From behind, the folio wins: chanoes are visible : The dorsal 
and lumbar curvatures of the spinal column have disappeared, 
and the shoulders have regained their natural elevation. The 
depression of the ribs on one side, and the projection on the 
other, are fast disappearing. The right half of the muscles of 
the neck still remain greatly developed above that of the other 
side, and a slight curve still exists in the cervical vertebrae. 
The health of the patient has greatly improved ; and his appear- 
ance is so completely altered since the operation, that his former 
friends scarcely recognize him. 

Case CCCLXXI. — Division of the Sterno-mastoid Mus- 
cle for Wry ISfech, — The following case was operated upon 
by Dr. John C. Warren, in the first part of June, 1841 : — 

The patient was a little girl, nine years of age. When about 
four weeks old, the parents observed that the muscles on the 
left side of the neck w^ere in an extraordinary state of tension : 
it w^as not, however, until the age of four years, that the head 
began to be distorted ; and from that period the distortion has 
gradually increased, so that the contraction became so great as 
to bring the mastoid process nearly in contact with the left 
shoulder, accompanied by a strong rotation of the head to the 
right. This distortion evidently had a great effect on the health 
of the child, wdio was pale, emaciated, and of a feeble consti- 
tution. A double lateral curvature of the spine existed, though 
not so marked as in the preceding case. 

Under these circumstances. Dr. Warren determined to divide 
the sterno-cleido-mastoid muscle of the left side, which was 
found to be strongly retracted, and was evidently the chief 
obstacle to the return of the head to the upright position. 

The operation was performed in the following manner : The 
head being supported so as to give sufficient projection and ten- 



606 MISCELLANEOUS CASES. 

sion to the diseased muscle, a narrow, sharp-pointed bistoury- 
was passed between the skin and its sternal attachment, from 
without inward : the edge of the knife was now directed upon 
the muscle, and the division accomplished. The knife was 
again entered at the same orifice, carried in front of the cleido- 
mastoid, and this head of the muscle divided in a similar man- 
ner. 

The result of the operation was an immediate alteration in the 
head to a more upright position. The wound healed in three 
days. The subsequent treatment was the same as that de- 
tailed in the preceding case. 

The following is the substance of a letter received from her 
father two months after the operation : He stated that she had 
perfect command of her head, and a power of rotation in all 
directions. Her head was so nearly straight that a stranger 
would not notice any deformity. "From the shoulders, her 
neck slopes to the right, which is apparent when standing 
behind her. The short curve at the upper part of the neck can 
scarcely be perceived. The cavity on the one side, and the en- 
largement on the other, have returned to almost the perfect 
shape. Her schoolmates are astonished when they see her 
with her head up, and say how tall she has grown. Her neck, 
you will probably remember, was apparently very short : it is 
now a very long neck for a child of her age. She occupies the 
inclined plane four hours each day." 

Remarhs. — In reviewing these cases, we shall find the fol- 
lowing circumstances worthy of notice : In the first place, the 
anatomical changes produced by the contraction of the muscle 
are very interesting, as bearing on many cases of deformity 
besides that now under consideration. The left half of the face, 
as has been already stated, had become more or less atrophied 
during the continuance of the disease ; so that the whole osseous 
system, as well as the soft parts, was implicated in the diseased 
action. The alteration has been attributed by M. Guerin to 
the distortion which the great vessels of the neck undergo before 
their entrance into the cranium. The curvature to the right, 
which the cervical vertebrae make on the dorsal, produces a 
strong traction of the skin, by which an oblique position is 



WRY NECK. 607 

communicated to the left part of the face. The eyeball also 
undergoes a rotation on its axis, so as to bring it into the hori- 
zontal direction ; the eyes, as M. Guerin remarks, being placed 
in relation to each other, as it were, on a staircase, from 
whence considerable trouble in vision is produced on the first 
adjustment of the head. The alteration in the spinal column is 
also interesting. In order to obviate the inclination of the 
head to the left, which brings it without the axis of the body, 
an inclination takes place of the cervical on the dorsal region, 
of the dorsal on the lumbar, and of the lumbar on the sacral. 
The depression of the ribs on the one side, and their projec- 
tion on the other, naturally follow from the persistence of the 
curvature in the spinal column. 

There are few operations that have been more benefited by 
the establishment of the principle of subcutaneous incisions 
than that for wry neck. The operation previously employed by 
distinguished surgeons consisted in first making a transverse in- 
cision through the skin, so as to expose the fibre of the sterno- 
mastoid : the muscle was then carefully dissected, layer by 
layer, until the whole was divided. The results of this method 
were often very severe : there was great inflammation, and sup- 
puration, frequently followed by infiltration of pus into the 
anterior mediastinum, sometimes causing the death of the pa- 
tient. The contraction, also, of the cicatrix from so severe a 
wound, often counteracted the benefit derived from the division 
of the muscle. 

To M. Guerin, of Paris, we are chiefly indebted for the ex- 
position of the pathology, physiology, and the surgical treat- 
ment of wry neck. M. Guerin has endeavored to establish 
the following propositions : — 

1st, That what has been called the sterno-cleido-mastoid 
muscle constitutes, in fact, two distinct muscles, — the sterno- 
mastoid and the cleido-mastoid. 

2d, The sterno-mastoid and the cleido-mastoid are possessed 
of different functions : the first is a flexor and rotator of the 
head, the other muscle is essentially a muscle of respiration. 

3d, In wry neck, which has thus far been attributed to the 
shortening of the sterno-mastoid, the sternal muscle is primi- 
tively alone affected. 



608 MISCELLANEOUS CASES. 

4th, That, in the treatment of chronic wry neck, owing to 
the shortening of the sterno-mastoid, the section of the sternal 
portion alone suffices to destroy the essential cause of the 
deformity. 

The practical inference to be drawn from them appears in the 
fourth proposition ; viz., that in the majority of cases, the sterno- 
mastoid is primarily affected, and this alone requires an opera- 
tion. Where the affection has lasted for a length of time, as in 
the two cases stated above, the cleido-mastoid almost always 
partakes in the diseased action ; and although, by a long persist- 
ence in the use of mechanical means, this may be sometimes 
overcome, yet the cure is undoubtedly much facilitated by its 
division. M. Guerin has drawn a distinction, worthy of notice, 
between what he calls the retraction and the contraction of the 
muscle. The former, he has endeavored to show, only takes 
place after a long persistence of disease, and consists in a fibrous 
degeneration of the muscle, and always requires surgical inter- 
ference ; whereas the latter, which occurs in acute wry neck, 
is a simple temporary shortening of the muscular fibres, such as 
occurs in common muscular action, and is always amenable 
to the use of local remedies, more particularly the application 
of the tartar-emetic ointment. 

The following is the most approved manner of performing the 
operation : The head of the patient, being firmly supported, is 
carried a little forward and strongly rotated, so as to project 
the muscle outward from the subjacent parts, and make it as 
tense as possible. A fold of skin over the muscle being raised, 
a puncture is made with a lancet from four to six lines above 
the clavicle, and between the insertions of the two heads of the 
muscle. The narrow, blunt-headed knife of Bouvier is, now in- 
troduced, and carried with its flat side between the muscle and 
the skin. The hold on the skin may now be relaxed, the edge 
of the knife applied to the muscle, and the division effected. 
This is usually announced by a crackling sound, and by the 
partial adjustment of the head. Instead of passing the knife 
in front of the muscle, it may be carried behind It ; but in this 
case it is well that the knife should have a different shape : in 
the former a concave, and in the latter a convex, edge is re- 



CONGENITAL FUSION OF FINGERS. 609 

quired. If it should now be determined to divide the clavicular 
head of the muscle, the knife may be introduced into the same 
orifice in the skin, carried backward, and the division made as 
in the preceding case ; the section of the muscle from without 
inward being here always to be preferred, as more safe and 
easy of execution. 

When the projection of the muscle from the parts beneath is 
sufficient to remove them from the danger of being punctured, 
and it has been determined to divide the body of the muscle, 
the method may be adopted which was practised in the former 
of the two cases which have been related. The body of the 
muscle just before its division being seized between the fingers, 
so that these are made to meet behind it and ascertain that no 
obstacle intervenes, a narrow-bladed knife is carried beneath, 
until the point is detected under the skin on the opposite side ; 
and the division is then to be made from within outward. 

In dividing the internal head of the muscle, we have occasion- 
ally beneath the skin the anterior jugular vein, as it passes 
across the neck to enter the subclavian. This, however, is 
easily avoided by making the incision sufficiently near the 
clavicle. The carotid and internal jugular are protected by 
the sterno-hyoid and sterno-thyroid muscles, and could not be 
reached but by the point of the knife carelessly introduced. In 
dividing the cleido-mastoid, the external jugular, which lies 
between the border of the muscle and the skin, may be wounded : 
this is avoided by raising the skin and passing the knife with its 
cutting edge perpendicularly to the muscle ; the vein being left 
between the back of the instrument and the skin. In dividins; 
the body of the muscle, the external jugular is the principal 
vessel to be avoided, and with sufficient c;ire can be easily left 
on the outside of the puncture necessary for introducing the 
knife employed in the operation. 



CONGENITAL FUSION OF FINGERS. 

Case CCCLXXII. — Oongenital Fusion of the Middle 
Fingers of both Hands. Operation. Cure. — I am led to 
record the following case, from the difficulty experienced, when 

77 



610 MISCELLANEOUS CASES. 

it was first bronglit to my notice, of procnrinfr any practical 
infornmtlon on tlie snbject from tlie surgical works generally 
referred to as authority. 1 was requested, iu October, 1857, to 
see a cliild, Avho had been born a few days before, with an inti- 
mate union of the middle and rins^ fino'ers of each hand. The 
cliild was a very fine one, and otherwise ])erfect ; its parents, 
remarkably handsome and well-formed. They were extremely 
anxious that some operation should be done to bring the fingers 
into a natural condition. On a careful inspection, I found 
the state of things as follows : — 

The conjoined finger of each hand had but a single nail, 
somewhat elongated on one hand, and showing a slight dis- 
position to break up into two. No fissure or depression could 
be distinguished marking the distinction between the two fingers, 
as may be observed in what is called webbed fingers. The 
finger was susceptible of flexion and extension ; but no appear- 
ance of separate joints could be observed, or separate bony 
structure : in ffict, there was apparently but one finger in place 
of two. I therefore advised that the operation should be de- 
layed, to afford sufficient time for the development of the dif- 
erent organs ; that the conjoined fingers should be seized, and 
made to work laterally one upon the other, so as to elongate, 
if possible, the uniting medium between the two. 

The preceding plan was adopted ; and, at the end of six 
months, the bony structure, joints, and other textures, were 
sufficiently developed to show the elements of two fingers in the 
mass, and warrant the attempt at an operation with a reasonable 
chance of separating them, without cutting into the joints, and 
producing stiffness or anchylosis. The operation was thus per- 
formed : — 

The child being etherized, the ends of the fingers, where the 
bony structure seemed to be united, were separated up to the first 
joint, by the cutting pliers. A careful dissection then se[)arated 
the fingers, fortunately without entering the joints, except pos- 
sibly the last joint of one finger on one hand, which might have 
been opened ; but this was doubtful, and not at all indicated by 
the subsequent progress of the case. The dissection was carried 
rather farther towards the hand than the natural division, in 



COXGEXiTAL FUSIOX OF FIXGERS. 611 

fact nearly down to the first or knuckle joint, in order to allow 
for a certain amount of adhesion or contraction, which it was 
thought no art or labor would be able to prevent. It was then 
attempted, at the angle and sides of the finger, to bring the 
skin of the back and palm of the hand in contact by means of 
sutures. This was effected, but with great strain of the integu- 
ments, on account of the thickness of the parts. A long piece 
of adhesive plaster was placed between the two fingers, and 
made to exert as great a pressure as possible on the angle of 
the wound. This was replaced from time to time, the use of it 
being maintained througliout the whole treatment. 

It will be unnecessary to go into all the minutije of the sub- 
sequent management of the case. It proved perfectly- success- 
ful, and left the child with two well-formed fingers, and tlie 
entire use of the joints. The nails, which had been divided, in 
the course of one or two months were covered on their cut 
surfiices by new skin and flesh, giving them quite a natural 
appearance. The cicatrix, which extended from the angle of 
the fingers upwards on each side, had a tendency to contract, 
and curve the fingers inwards ; and tliis, rather than the dispo- 
sition of the fingers to again unite, Avas the principal point 
which required attention towards the end of the treatment. It 
was thought useless, at the early age of the patient, to attempt 
any mechanical means to obviate this contraction, which was 
counteracted by the constant attention of the mother, in soaking, 
and forcibly bending them out. The result of the operation 
was, in place of a very great deformity, to restore the hand to 
a useful condition, and to an appearance which would pass 
without remark. 

I have often operated to remove supernumerary fingers and 
toes from infants, and invariably with good results. Some- 
times two fingers or toes are placed on the same joint, each hav- 
ing its peculiar facet in the joint. When the patient is very 
young, and the additional excrescence on the outside of the 
finger or toe, I have not seen any inflammation of the joint 
ensue from removing it. At a later period, when tiie joint is 
more fully organized, it appears best to cut off the head of 
the bone just short of the joint, which, it' neatly done, shows 



612 MISCELLANEOUS CASES. 

but little afterwards. I have lately operated on the following 
case : A little girl, eight years of age, had two terminal bones 
on the last joint of the thumb, with two nails ; the two bones 
springing from one joint. By dissecting up the skin, I removed 
the outer one, with part of the base, without interfering with 
the joint ; and the deformity remaining after the operation was 
very slight. 

I have twice seen persons with a single enormous finger, 
appearing as if viewed through a magnifying glass. The fol- 
lowing remarkable exuberance of growth and deformity of the 
foot is the only one of the kind that 1 have met with : — 

Case CCCLXXIII. — Malformation of Foot. — A woman, 
about 30 years of age, applied to me for an injury of her foot, 
which, she said, was a remarkable one, being congenitally de- 
formed ; and this I found to be the case. The foot, as far as the 
great toe, on the inside, was natural ; and, on the outer aspect, 
were two natural toes. Springing from between these was 
what appeared to be another fleshy foot, terminated by the 
rudiments of toes buried in the end of it. On a careful mani- 
pulation, the osseous part of it was found to be composed of 
two large bones, apparently the metatarsal : there was no power 
of flexion in this part of the foot. On the dorsal aspect, and at 
the junction of this foot with the other, was what appeared to 
be a ganglionic swelling, which was quite tender, and had 
been caused by a strain. This yielded to treatment in a week 
or two. The length of the foot was thirteen inches. 

I lately measured the foot of a man six feet six inches high, 
at the Hospital, and it was found to be a little less than twelve 
inches in length. 

Mr. Anandale has recently written an interesting book on 
" Deformities of the Fingers and Toes," in which are cases 
somewhat similar to those given above. 



CHAPTER XIV. 

ANESTHETICS. 

The change made in the practice of surgery by the discovery of 
the anaesthetic power of ether can scarcely be appreciated by 
those who have come on the stage since the introduction of this 
agent. It was in the city of Boston, a httle more than twenty 
years since, that the full value of this discovery was first de- 
monstrated and published ; and it is truly remarkable, that, 
at the present day, artificial anaesthesia is best attained by sul- 
phuric ether, used in substantially the same manner as when it 
was first tried in surgical operations at the Massachusetts Gen- 
eral Hospital. While chloroform is acknowledged to be dan- 
gerous, and while the foreign medical journals contain frequent 
notices of death from the use of this potent agent, it is a striking 
fact, that, out of the hundreds of thousands of cases of etheri- 
zation, the first undoubted case of death from its action is yet to 
be recorded. It is not pretended by this statement to abjure the 
use of chloroform, which, in some cases, is certainly preferable 
to any known anaesthetic ; being far more concentrated in form, 
more agreeable, and more active in administration, than any of 
the many substitutes which have been proposed for it. On the 
battle-field, especially, its greater portability is likely always to 
secure the preference for it over safer but more bulky ani^s- 
thetics. 

The first and perhaps the most important application of ether 
is in producing unconsciousness of pain ; and it is for this boon 
that the patient will ever be chiefly thankful. To the surgeon, 
also, the non-infliction of pain is often a matter of the greatest 
moment ; for he can now undertake a long and tedious dissection, 
or a delicate exploration of an acutely inflamed cavity, undls- 



614 ANESTHETICS. 

turbed by the involuntary movements of the patient. The power 
to abolish pain has also materially enlarged the domain of opera- 
tive surgery, not only by diminishing the dread of common 
operations, and allowing of their more frequent performance, 
but also by admitting into the list of justifiable operations some 
whose severity would otherwise, in most cases, forbid even the 
thought of attempting. 

The other great application of ether in surgery depends upon 
its power of relaxing the voluntary muscles by Inducing a state 
of the brain analogous to coma. In the deep sleep of complete 
etherization, the manipulation and reduction of fractures and 
dislocations, the diagnosis and treatment of anchyloses, the re- 
duction of strangulated hernia, &c., are immensely facilitated. 
The question of its use in certain special departments of sur- 
gery will be noticed elsewhere. 

This is not the place to dwell on the very important uses of 
ether in midwifery, and in painful or convulsive medical diseases ; 
but of its inestimable value in the alleviation of sufFerins: durins^ 
the last moments of life, I cannot omit this passing notice. 

Having been conversant with the principal facts relating to 
the introduction of the inhalation of ether for surgical operations 
from the beginning, it may not be considered inappropriate to 
give, in this place, a slight sketch of its early history, more 
especially as, since the introduction of chloroform, and its 
almost complete adoption abroad, the origin of etherization 
seems in dano^er of beinij: lost sls-ht of. The fixcts, so far as I 
am acquainted with them, are briefly as follows : — 

In tlie autumn of 1846, Dr. W. T. G. Morton, a dentist in 
Boston, a person of great ingenuity, patience, and pertinacity 
of purpose, called on me several times to show some of his 
inventions. At that time, I introduced him to Dr. John C. 
Warren. Shortly after tliis, in October, I learned from Dr. 
Warren, that Dr. Morton had visited him, and informed him 
that he was in possession of, or had discovered, a means of pre- 
venting pain, which he h'^^d proved in dental operations, and 
wished Dr. Warren to give him an opportunity of trying it in 
a surgical operation. After some questions on the subject, in 
regard to its action, and the safety of it, Dr. Warren promised 



ANESTHETICS. 615 

tliat hn \youlcl do so. On the Tuesday following, Oct. 13th, 
after the surgical visit at tlie Hospital, a patient was brought 
into the anipliitheatre for operation. This being tlie first op- 
portunity which liad occurred since Dr. Warren's promise to 
Dr. Morton, Dr. Warren said to us : "I now remember that I 
have made a promise to Dr. Morton to give him an opportunity 
to try a new remedy for preventing pain in surgical operations," 
and asked the patient if he should like to have the operation 
done without suffering. He naturally answered in the affirma- 
tive. The operation was therefore deferred until Friday, Oct. 
16th, when the ether was administered by Dr. Morton with his 
apparatus, and the operation performed by Dr. Warren. It 
consisted in the removal of a vascular tumor of the neck, which 
occupied five minutes. During a part of the time, the patient 
showed some marks of sensibility ; but subsequently said that he 
had no pain, although he was aware that the operation was pro- 
ceeding. On the following day, a woman requiring the removal 
of an adipose tumor from the arm was rendered insensible by 
ether, given by Dr. Morton ; and Dr. Warren requested Dr. 
Hay ward, who was present, to perform the operation. This 
Avas successful ; the ether being continued through the whole 
operation, which was a short one, and the patient being entirely 
insensible. 

A few days afterwards. Dr. Warren informed me that he had 
learned from Dr. Charles T. Jackson that he had suo-oested 
the use of ether to Dr. Morton. 

The success of this process in the prevention of pain was now 
quite established. Its use, however, was suspended for a time, 
for reasons which Dr. Warren has already given in his first 
paper on ether ; and the experiments were not again resumed 
until Nov. 7th, when Dr. Morton declared his willino^ness to 
state the nature of the agent employed. Two important opera- 
tions were now done successfully at the Massachusetts General 
Hospital under its agency : one, an amputation of the thigh, 
by Dr. Hayward ; the other, a very difficult and bloody opera- 
tion, — removal of a portion of the upper jaw in a woman, — by 
Dr. Warren. On the same day, I operated on an Infmt for 
hare-lip ; but, as we had thus far had little experience in the use 



616 ANESTHETICS. 

of ether, it was not thought prudent to employ it with so young 
a child. With a more full experience, however, I have since 
given it, in this operation, at the earliest ages of life ; in one, 
between six and ei^ht hours after birth. 

On Nov. 12th, I performed the first successful operation 
under ether which was done in private practice, on a young 
woman, for a tumor of the arm. The ether was administered 
for three minutes, when the patient became unconscious. The op- 
eration then proceeded, the inhalation being continued. The 
patient was so entirely tranquil, that Dr. J. C. Warren, who 
was standing by her side, was not aware that the operation had 
commenced until it was nearly completed. Nov. 21st, I did 
another operation in private practice, at which many of the pro- 
fession were present, — the removal of a formidable tumor of 
the thigh, which is thus described by Dr. J. C. Warren : — 

" The patient lying upon a bed, the vapor was administered by 
Dr. Morton, in the presence of Drs. C. T. Jackson, Reynolds, 
J. y. C. Smith, Flagg, Gould, ShurtlefF, Lawrence, Parsons, Briggs, 
and others. After he had breathed the vapor for three minutes, 
his head fell, and he ceased to respire it ; but, presently awaking, the 
inhalation was renewed until he again appeared insensible. The 
operation Avas tlien commenced. At the first stroke of the knife, he 
clapped his hand on the wound ; but I immediately seized and held it 
during the remainder of the operation, though not without some diffi- 
culty, in consequence of his struggles. The operation was completed 
in two or three minutes, and the patient remained quietly on his back, 
with his eyes closed. On examination, the pupils were found to be 
dilated ; the pulse was not materially affected. After he had lain 
about two minutes, I roused him by the inquiry, ' How do you do 
to-day ? ' to which he replied, ' Very well, I thank you.' I then asked 
what he had been doing. He said he believed he had been dreaming : 
he dreamed that he was at home, and making some examination into 
his business. ' Do you feel any pain ? ' — ' No.' — ' How is that tumor 
of yours ? ' The patient raised himself in bed, looked at his thigh 
for a moment, and said, ' It is gone, and I'm glad of it.' I then 
inquired if he had felt any pain during the operation, to which he 
replied in the negative. He soon recovered his natural state, expe- 
rienced no inconvenience from the inhalation, was remarkably free 
from pain, and in three days went home into the country." 



ANAESTHETICS. 617 

The preceding operations at tlie Hospital were followed by a 
variety performed there by the other surgeons of the Institution, 
— Drs. S. D. Townsend, S. Parkman, H. J. Bigelow, and 
myself. 

The use of ether in surgical operations being sanctioned by 
the Medical Board of the Hospital, the Consulting Board, and 
the Board of Trustees, — the last composed, as it always is, of 
distinguished and prominent men of Boston, having in charge 
important trusts,* — was, after some little resistance, gradually 
adopted throughout this country, and at once made use of by 
surgeons in Europe. 

About a year after the discovery of the anassthetic power of 
ether, chloroform was introduced, and, from its fascinating 
qualities, seemed likely to displace ether, which had the disad- 
vantage of being disagreeable to the smell and taste, and ob- 
jectionable under certain circumstances, from its inflammability. 
Very soon, however, fatal accidents began to be caused by 
chloroform ; many of them occurring where it was given for 
minor operations. The proportion of deaths has continued up 
to the present time, and may be estimated at about one a month 
for the last twenty years ; which ratio seems scarcely reduced by 
the use of any care or ingenuity. 

Dr. John C. Warren and myself introduced into practice, 
and used for about five years, concentrated chloric ether, pre- 

* Officers of the Massachusetts General Hospital, 1846. — William 
Appleton, President ; Theodore Lyman, Vice-President ; Henry Andrews, Treas- 
urer ; Marcus Morton, Jr., Secretary. 

Trustees. — Charles Amory, William T. Andrews, Nathaniel I. Bowditch, 
George M. Dexter, Robert Hooper, Thomas Lamb, Francis C. Lowell, John A. 
Lowell, Henry B. Rogers, J. Thomas Stevenson, J. Wiley Edmands, Edward 
Wiggles worth. 

Board of Consultation. — James Jackson, M.D. ; John Jeffries, M.D.; George 

C. Shattuck, M.D. ; Edward Reynolds, M.D. 

Visiting Physicians. — Jacob Bigelow, M.D. : Enoch Hale, M.D. ; John B. S. 
Jackson, M.D.; Henry I. Bowditch, M.D. ; John D. Fisher, M.D. ; OKver W. 
Holmes, M.D. 

Visiting Surgeons. — John C. Warren, M.D. ; George Hay ward, M.D. ; Solomon 

D. Townsend, M.D. ; J. Mason Warren, M.D. ; Samuel Parkman, M.D. ; Henry 
J. Bigelow, M.D. 

Of the McLean Asylum. — Luther V. Bell, M.D., Physician and Super- 
intendent. 

78 



618 ANESTHETICS. 

pared by distillation after a process recommended by Dr. A. A. 
Hayes. It had the advantage of being very agreeable to the 
taste, not inflammable, easily manageable, safe, and a good sub- 
stitute for chloroform. Its liability to adulteration, and some 
accidents which subsequently occurred, probably from that cause, 
after its use became extensive through the country, led us to 
abandon the responsibility of recommending it, and to return 
to the use of sulphuric ether. 

Ether was first administered by an apparatus. The use of 
this was inconvenient, especially with children, and led me to 
administer it on a simple sponge, which immediately took the 
place of the apparatus everywhere. The sponge first used at 
the Hospital is still preserved there. 

In the course of twenty years, as already stated, not a single 
death can be fairly attributed to the use of sulphuric ether. In 
the Massachusetts General Hospital alone, it has been employed 
over twenty thousand times, without a single unfavorable occur- 
rence. In some cases, particularly in young persons and 
females, I have seen disagreeable and troublesome symptoms 
occur from prolonged etherization. From the great frequency 
of the use of artificial teeth, the following not unusual acci- 
dent may be mentioned. In one instance, after operating upon 
a lady, under ether, for a tumor of the thigh, I found her in 
an apparently dying state ; respiration having almost ceased, 
and the pulse being just perceptible. Passing my finger down 
the throat, in order to admit a current of air to the larynx, 
I discovered an entire upper set of artificial teeth closely forced 
down on the glottis. These being withdrawn, it was only after 
a long persistence in the use of the usual remedies employed to 
recover a person from drowning, that the regular course of 
respiration and circulation was restored. She then became 
violently delirious for a time, but recovered well. I have once 
or twice, in the course of etherization, found artificial teeth 
loose in the mouth ; and now generally inspect it previously, 
when I have suspicions of their presence. 

Patients subjected to long operations — such as difficult 
vesico-vaginal fistula in women, and cases requiring perineal 
section in men — should be allowed, from time to time, to 



ANESTHETICS. 619 

partly recover from the ether, and get a supply of fresh atmos- 
pheric ah' into the lungs. Otherwise, from the position of the 
patient, which interferes with the abdominal respiration, and 
from the system becoming completely saturated with the anaes- 
thetic agent, I have seen an unpleasant and prolonged depres- 
sion occur a number of times, causing considerable anxiety. 

For army use, chloroform will undoubtedly take the place of 
ether. From the prejudice in favor of ether in this country, it 
was thought that, during the late war, it might be substituted 
for chloroform. This, in practice, has been found not to be the 
case ; the greater portability of the latter outweighing its dan- 
gers. In fact, to a surgeon on the field of battle, it would 
probably have been found necessary to have abstained from the 
use of anaesthetics, if such a bulky and explosive article as ether 
had required transportation. 

The following is the result of the use of anaesthetics in the 
army, as given in Circular No. 6 : — 

" There have been consulted, in regard to the employment of anaes- 
thetics, the reports of 23,260 surgical operations performed on the 
field or in general hospitals. Chloroform was used in sixty per cent 
of these operations, ether in thirty per cent ; and, in ten per cent of 
the cases, a mixture of the two was administered. At the general 
hospitals, the greater safety of ether, as an auEesthetic, was commonly 
conceded. It was often employed, and no fatal accident from its use 
has been reported. In the field operations, chloroform was almost 
exclusively used. The returns indicate that it was administered in 
not less than eighty thousand cases. In seven instances, fatal results 
have been ascribed, with apparent fairness, to its use." 

In six of these fatal cases, the operations were trifling ; and 
in one only was it administered for a capital operation. 

In civil practice, ether will probably, from its greater safety, 
gradually take the place of chloroform ; and this is already being 
done in some of the great cities and hosj^itals abroad. Pro- 
fessor Petrequin, ex-chief surgeon of the Hotel Dieu, of Lyons, 
has recently presented to the French Academy of Sciences an 
article styled, " Clinical Studies on the Injurious Effects of Chlo- 
roform on the Best Constitutions and all Ages, and on the 
Necessity of substituting for it Rectified Ether." 



620 ANESTHETICS. 

It will be observed, that the supporters of chloroform lay 
much stress on the method of its administration by an in- 
strument, or otherwise, in order to measure the quantity given, 
and proper admixture with atmospheric air, from the fear of 
dangerous consequences. No fear or precaution of this kind 
is to be apprehended or required in the use of ether. In fact, 
the more liberally it is poured on the sponge or towel at first, the 
more rapid and perfect is the etherization, — the intermediate 
stage of excitement being avoided, — and the quicker the patient 
expels it from the system after the operation. In children who 
resist violently, one or two screams so effectually empty the 
lungs of atmospheric air, which is at once replaced by the vapor 
of ether, that insensibility is almost immediate. 

Previous to a surgical operation, — which, it maybe here 
said, is always best done in the morning, unless forced otherwise 
by circumstances, — the patient should take no solid food ; thus 
avoiding the occurrence of vomiting, which not only depresses 
him, but much embarrasses the proceedings of the operation. 

After the operation, it is best to leave the patient to recover 
gradually, and perhaps to sleep off the effects of etherization, 
rather than to rouse him suddenly, and subject him to excite- 
ment, nausea, or headache. 

A caution may be given in regard to the inflammability of 
ether, during the night, where artificial light is necessary for the 
])erformance of operations, and in obstetric cases. In one in- 
stance, while operating at the Hospital at night on a mutilated 
finger, the lamp being three feet distant, and a sponge placed 
over the patient's mouth, the air in the vicinity became saturated 
with the ether, ignited, setting fire to the sponge, bed-clothes, 
and even face of the patient. The flames were fortunately, in 
this case, extinguished without any injury to the patient, but not 
without causing great fright to those in the neighboring beds. In 
another instance, the same accident took place from the intro- 
duction of a red-hot iron into the mouth of a patient, from whom 
the sponge containing ether had just been withdrawn. The 
flames were fortunately at once extinguished with water, which 
was immediately at hand. These accidents need only to be 
mentioned to be avoided. 



ANESTHETICS. 621 

The importance of having the ether properly prepared and 
thorouglilj washed, so as to free it from alcohol and other 
irritating substances, should be carefully looked to. Otherwise, 
the action of it is disagreeable at the time, highly irritating, and 
its subsequent unpleasant effects more protracted. This was a 
fact early pointed out to me by Dr. Charles T. Jackson. 

The anaesthetic action of cold, developed by a refrigerating 
mixture of ice and salt, as suggested by Mr. Arnott, may be ad- 
vantageously substituted for etherization in many cases of slight 
operations confined to the skin and subcutaneous tissues. The 
operation must be performed quickly, as the parts thaAV with 
great rapidity as soon as the warm blood begins to flow from 
the divided vessels. For operations requiring nice dissection, 
the method is inapplicable, owing to the rigidity of the frozen 
parts. There are many cases, however, especially minor opera- 
tions, which present themselves at the house of the surgeon, 
which scarcely authorize the disturbance of the system or delay 
which the administration of ether would require. For these, 
local anesthesia is of great value. 

In 1852, I operated, at the Massachusetts General Hospital 
and elsewhere, with Mr. Arnott's freezing mixture of pounded 
ice and salt ; and, from that time to the present, have frequently 
used it, as have many other surgeons in this vicinity, both for 
removino; small tumors, and makino- incisions in inflamed tissues. 
It Is best applied by placing the mixture in small bags of gauze, 
and having a number ready to be applied successively, rather 
than to depend on a single one ; the freezing process, by this 
means, being more rapidly produced. Lately, a much more 
convenient method of effecting complete local insensibility has 
been demonstrated by Dr. Richardson, of London, by the in- 
vention of an apparatus for the rapid evaporation of ether, 
applied to the diseased part. This has been improved on by 
Dr. H. J. Bigelow, by substituting an agent which he has 
named rhigolene, which produces a much more rapid reduction 
of temperature than any other substance hitherto employed. A 
temperature of — 16° of Fahrenheit can be arrived at in one 
minute with this substance. 



622 ANESTHETICS. 

One of the objections which, it was thought, would prevent 
the free use of rhigolene was its inflammable nature, and the 
danger of explosion in warm weather ; its boiling point being at 
70°. I have kept it during the summer, used it in many cases, 
and have thus far experienced no accident, nor heard of any 
occurring. I have tried it in cases of cancer of the lip, face, 
and nose ; and, with proper management, and sufficient time 
for its successive application, it might be employed in the re- 
moval of large tumors involving superficial textures. 

The nitrous-oxide gas is now being very extensively used by 
the dentists of this city ; its inhalation being much facilitated 
by recently improved valvular apparatus, which allows of the 
constant supply of the gas unmixed with the pulmonary ex- 
halations. Thus far, I am not aware of any fatal results from 
its use. It is very pleasant to inhale, and the recovery from its 
effects is usually immediate. It is very doubtful, however, that 
it will be adopted for any of the greater operations in surgery. 



INDEX. 



1 ^M) E X. 



A. 

Abdomen, Chapter V. 

„ Gunshot Wound of, 561. 

„ Stab in, 570, 571. 

Absence of Vagina and Uterus, 306. 308. 
Adipose Tumor of Hand, 521. 

„ Tumors of Spermatic Cord, 248. 
Air-passages, Foreign Bodies in, 96. 
Alden, Dr., 345. 
Allarton, Mr., 223. 
Amputation of Arm, 386, 390, 461. 
„ of both Thighs, 401. 

„ Hip-joint, 402, 407. 

„ of Leg, 391, 392, 394, 395. 

„ Shoulder-joint, 387-389. 

„ of Thigh, 395, 397, 400, 523, 

524, 525, 527, 565. 
Amputations, 384. 

„ Table of, 409. 

Amussat, M., 197, 204. 
Aneesthesia, Local, 621. 
Anaesthetics, Chapter XIV. 
Anandale, Mr., 612. 

Aneurism by Anastomosis, 443, 451, 457. 
„ of Abdominal Aorta, 437. 

„ of Popliteal Artery, 433. 

,, of Subclavian Arterv, 425, 427, 

429. 
„ of Thoracic Aorta, 434. 
„ VaiMcose, of Hand and Arm, 

461. 
Aneurismal Tumors and Ligature of Ar- 
teries, 424. 
Anus, Chapter VL 

„ Artificial, 168, 169, 175, 177. 
„ Fissure of, 186-189. 
„ Fistula of, 191. 

„ Imperforate, 196, 198, 199, 201, 202. 
„ Prolapse of, 194. 
Appendix Vermiformis, Gangrene of, 575. 
Arm, Tumor of, 519. 
Arnott, Mr., 460_, 621. 
Arteries and Veins, Chapter IX. 
Artery, Vertebral, Wound of, 553. 
Avery, Mr., 129. 
Axilla, Tumor of, 518. 

B. 

Bacon, Dr. John, 212, 213. 
Ball, Dr., 592. 



Barnes, Surgeon-General U. S. A., 542. 
Bartlett, Dr. Josiah, 433. 
Barton's Operation, 417, 420. 
Beaumont, Mr., 223. 
Bell, Benjamin, 197. 
„ Johii, 441, 442. 
Bennet, Dr., 75. 
Bennett, J. Hughes, Dr., 480. 
B^rard, M., 488. 

Bigelow, Dr. Henry J., 462, 617, 621. 
Bladder, Stone in, 204-226. 

„ Wound of, 241. 
Blake, Dr. J. G., 163. 
Bodenhamer, Dr. William, 201. 
Bond, Dr. Henrv, 321. 
Bowditch, Dr. H. L, 147, 149, 151. 
Boyer, M., 332. 
Brain, Concussion of, 16. 
Breast, Cancer of, 512, 514, 515, 517. 

„ Chronic Inflammation of, 511. 

„ Cystic Tumor of, 509. 

„ Erectile Tumor of, 510. 

„ Male, Tumor of, 518. 
Briggs, Dr., 41, 497, 616. 
Broadbent, Dr., 483. 
Bronchus, Foreign Bodies in, 97, 100, 102, 

104. 
Brown, Dr., 169, 173. 
Brown, Dr. Buckminster, 154, 292, 424, 

430, 573. 
Brvant, Mr., 230, 348. 
Buck, Dr., 323. 
Bumstead, Dr., 339. 



Cabot, Dr. Samuel, 108, 354, 363, 404, 533, 

587, 595. 
Calculus, Cystic Oxide, 212, 214. 

„ Oxalate of Lime, 207, 209, 216, 

220, 223. 
,, Renal, in Female, 304. 
„ Salivarv, 94. 
„ Triple Phosphate, 218, 221. 
„ Vesica], in Female, 303. 
Cancer, Epithelial, 47, 481. 

„ of Breast, 481, 482, 512, 514, 515, 

517. 
„ of p]ar, 59. 
„ of Eye, 55, 56. 
„ of Genitals, 244. 
„ of Lip, 49. 



626 



INDEX. 



Cancer of Nose, 52. 

„ of Parotid, 490, 491, 493. 

„ of Rectum, 243. 

„ of Tongue, 93. 

„ of Tonsils and Throat, 125. 

„ of Vulva, 272. 

„ Table of Operations for, 536. 
Cancerous Tumors of Jaw, 80. 
Carotid, Ligature of left, 439. 
Carotids, Ligature of both, 446. 
Cases of Trephining for Epilepsy, Table 

of, 15. 
Cellular Tissue, Induration of, 600. 
Cervix Uteri, Hypertrophy of, 294, 299. 
Chancre of Lip resembling Cancer, 51. 
Cheek, Erectile Tumor of, 534. 

„ Recurrent Tumor of, 499. 
Chest, Gunshot Wound of, 550, 560. 

„ Stab in, 570, 571. 

„ the, Chapter IV. 
Cheever, Dr. D. W., 203, 501. 
Chloric Ether, 617, 618. 
Chloroform, 613, 617, 618. 
Circular No. 6, 542, 569, 619. 
Civiale, M., 204, 212. 
Clark, Dr. Henry G., 108, 162, 557, 570. 
Coale, Dr., 586. 
Coccyx, Injuries of, 593-596. 
Collis, Mr., 129, 131, 135. 
Concussion of the Brain, 16. 
Congenital Fusion of Fingers, 609. 
Cooper, Mr. Bransby, 376. 

„ Sir Astlev, 204, 324, 332, 354, 
358, 359, 376, 449. 
Cord, Tumors of Spermatic, 248. 
Costello, Mr., 487. 
Coulson, Mr., 120. 
Cox, Dr., 200. 
Crampton, Sir Philip, 135. 
Cranium, Fractures of, 1. 

„ Wound of, 6, 555. 
Crepitation of Tendons, 580, 581, 582. 
Crosby, Dr. Josiah, 323. 
Croup, 108. 
Cruikshank, Mr., 466. 
Curling, Mr., 252. 
Curtis, Dr., 586. 

Cuyler, Dr., Surgeon U. S. A., 544. 
Cystic Tumor of Breast, 509. 

„ „ of Jaw, 72. 

„ „ of Tibia, 522. 

„ „ of Vagina, 273. 



D. 

Damon, Dr. H. F., 501. 

Davidson, Dr. H. E., 110. 

Delpeck, 36. 

Depression of Skull, 7-9, 12. 

Desault, M., 323. 

Deviation of Septum Nasi, 62. 

Dickson, Dr. R. E., 70, 139. 

DiefFenbach, 18, 19, 29, 129, 134. 

Digital Nerve, Excision of, 475. 

„ „ Neuralgia of, 475, 476, 477. 

Dislocation of both Thighs, 364. 

„ of Elbow, Lateral, 362. 

, of Femur, Dorsal, 364-366, 

368-370. 



Dislocation of Femur backwards, and 
probably downwards, 381. 
„ of Femur into Foramen Ovale, 

364, 378, 379. 
,. of Femur downAvards, 372. 

„ of Femur, Perineal, 369, 371. 

„ of Femui', with Fracture of 

Socket, 381. 
„ of Shoulder backwards, 358. 

„ of Shoulder forwards, 354, 

356, 360. 
„ of Shoulder, with probable 

Fracture of the Socket, 357, 
361. 
Dislocations, 348. 

,, Table of, 384. 

Drowning, Resuscitation after, 598. 
Dupuytren, M., 72, 73, 120, 168, 170, 206, 

220, 222, 322, 458. 
Dyer, Dr. Ezra, 312, 406, 408. 

E. 

Ear, Epithelial Cancer of, 59. 
„ Fibrous Tumor of, 59. 
„ the, 59. 
Elbow, Lateral Dislocation of, 362. 
Ellis, Dr Calvin, 11, 305, 315, 404, 499, 

503, 524, 556. 
Enchondroraa of Finger, 520. 
Encysted Tumor of Tongue, 92, 93. ' 
Epilepsy, Trephining for, 7. 

„ „ „ Table of Cases, 15. 

Epithelial Cancer, 47, 481. 

„ „ of Nose, 52. 

„ „ of Vulva, 272. 

Epulis, 70. 

Erectile or Vascular Tumor, 441. 
„ Tumor of Breast, 510. 
„ „ of Cheek, 534. 

„ „ of Ear, 457. 

„ „ of Face and Neck, 446. 

„ „ of Hand and Arm, 461. 

„ „ of Head, 451. 

„ ' „ of Knee, 460. 

„ „ of Mouth, 462. 

„ of Scalp, 443. 
Erichsen, Mr., 73, 223, 376, 406. 
Ether, 613, 614, 616, 617. 

„ First Operation under, 615. 
Excision of External Condyle of Hu- 
merus, 410. 
„ of Joints, 409. 
„ of Joints, Table of, 423. 
„ of Knee-joint, 412, 415, 416, 417, 

420. 
„ of Shoulder-joint, 411, 423. 
Extraction of Needles, 590. 
Extremities, the. Chapter VIII. 
Eye, Cancer of, 55. 
„ „ of. Melanotic, 56. 
„ the, 55. 
Eyelid, Restoration of Lower, 42. 



Face and Neck, 504. 
„ and Orbit, Tumor of, 499. 
„ Horn upon, 61. 
„ the. Chapter II. 



INDEX, 



627 



Femur, Dislocations of, 353, 364-382. 
Ferguson, Sir William, 69, 129, 132. 
Fibrous Tumor of Ear, 59. 
„ Tumors of Jaw, 84. 
„ Tumor of Thigh, 530, 531. 
Field, Mr., 129. 
Finger, Eiichondroma of, 520. 
Fingers, Congenital Fusion of, 609. 
Fissure of Anus, 186. 
„ of Palate, 126. 
Fistula in Ano, 191. 

„ Urethral, from Wound, 235. 
„ Vesico-rectal, 234, 242. 
„ „ vaginal, 263-268. 

Fistulous Opening containing Hair, 192, 

193 
Flagg, Dr., 323. 016. 
Folts, Dr., 350. 
Foot, Malibrmation of, 612. 
Foreign Bodies in Air-passages, 96. 
„ „ in CEsophagus, 112. 

„ Body in Vagina, 276. 
Fox, Dr., 320. 

„ J. L., Surgeon U. S. Navy, 544, 552. 
Fracture of Arm, 331. 

„ of Arm imitating Dislocation of 

Elbow, 362. 
„ of Base of Skull, 3, 4, 597. 
,, of Clavicle, 320. 
,, of Coccyx, 595. 
„ of Condyles of Humerus, 321. 
„ of Epiphysis of Head of Hu- 
meras,"^328. 
of Femur, 323, 324, 341, 382, 516. 
„ of Fore-arm, 331. 
,, of Humerus ununited, 329. 
„ of Malar Bone, 326. 
„ of Malar Bone and Sup. Maxil- 
lary, 327. 
„ of Neck of the Femur, 340-342, 

345, 346. 
„ of Neck of the Femur, with In- 
version of Foot, 342. 
„ of Patella, 322, 332-338. 
„ of Pelvis, 339. 
„ of Radius, 321, 330. 
„ of Skull, 2, 6, 12, 555. 
„ of Spine, 324. 
„ of Superior Maxillary Bones, 
327. 
Fractures, 318. 

„ of Cranium, 1. 

Fungoid Tumor of Forehead, 483. 

G. 

Gangrene of Appendix Vermiformis, 575. 
Gay, Dr. G. H., 108, 404. 
Genital Organs, Cancer of, 244. 
Genito-urinary Organs, Chapter VII. 
„ „ " ,, Female, 258. 

Male, 204. 
Gensoul, 69. 
Gibbs, Mr., 118. 
Gibson, Dr. C. B., 545. 
Gilman, Dr., 86. 
Gordon, Dr. Ciiarles, 547. 
Gould, Dr. A. A., 333, 616. 
Graefe, 18, 36, 126. 
Greeley, Dr., 372. 



Green, Dr. John, 386. 

„ Dr. S. A., 382. 
Groin, Wound of, 565. 
Gross, Professor, 72, 96, 97, 175, 246. 
Guerin, M., 603, 606, 607, 608. 
Gunshot Wounds (see Wounds), Chapter 

XII. 
Guthrie, Mr., 543, 569, 578. 

H. 

Hematocele, 252. 
Haighton, 466. 
Hale, Dr., 107. 
Hamilton, Professor, 319. 
Harelip, 143. 
Hayes, Dr. A. A., 618. 
Hayward, Dr. George, 164, 615. 
Head, Gunshot Wound oi", 6, 543, 555. 
„ the. Chapter I. 
„ Tumor of, 483, 485-487. 
Hemorrhoids, 183-186. 
Hennen, 543. 
Hermaphrodism, 310. 
Hernia, 152. 

„ Radical Cure of, 164-168. 
„ Strangulated, 152-164. 
Heurteloup, M., 204. 
Heywood, Dr. C. T., 41. 
Hip and Spinal Diseases, 572. 
Hip-joint, Amputation at, 402, 407. 
Hodges, Dr. R. M., 313, 443, 462. 
Hooker, Dr., 10. 
Horn on the Face, 61. 
Horns, 60. 

Hosack, Dr. A. E., 270. 
Huguier, M., 294, 295, 298. 
Humerus, Amputation of, 386, 390, 461. 

„ Dislocation of, 354, 356-358, 

360, 361. 

„ Excisionofext. Condyle of, 410. 

„ „ of Head of, 411, 423. 

„ Fracture of, 331, 362. 

„ „ of Condyles of, 321. 

,, „ of Epiphysis of Head 

of, 328. 

„ ,, of ununited, 329. 

Hutchinson, Mr., 49, 53, 270. 
Hydrocele, 251 

„ of the Neck, 509. 

Hydrophobia, 584. 
Hypertrophy of Cervix Uteri, 294, 299. 



I. 



Iliac Tumor, 179. 

Imperforate Anus and Rectum, 196. 

Inches, Dr. H. B., 37, 38. 

Indurated Tumor of Penis, 245-248. 

Induration of Cellular Tissue, 600. 

Injuries and Diseases of Nerves, Chap. X, 

„ of Os Coccygis, 593-596. 

„ of the Scalp, 15. 



J. 



Jackson, Dr. C. T., 615, 616, 621. 
„ Dr. James, 181, 189. 
„ Dr. John B. S., 109, 201, 313, 
333, 526. 



628 



INDEX. 



Jaw, Cancerous Tumors of, 80-84. 

„ Cystic Tumors of, 72-80. 

„ Fibrous Tumors of, 84. 

„ Myeloid Tumors of, 64-70. 

„ Necrosis of, 88-92. 

„ Removal of Lower, 66, 70, 78, 82. 

„ „ of Upper, 67, 81, 82, 84. 

,, Trephining Lower, 472, 474. 
Jaw-bone, Tumors of, 64. 
Joints, Excision of, 409. 
Jones, Dr., 461. 

K. 

Keep, Dr. N. C, 89. 

Knee and Elbow Joint, Gunshot Wound 

of, 563. 
Knee-joint, Excision of, 412, 415-417, 420, 
423. 

„ „ Naevus of, 460. 

„ „ Needle penetrating, 590-592. 

L. 

Labat, M., 18, 28. 

Larrey, M., 543. 

Laryngitis, Tracheotomy in, 109. 

Larynx, Foreign Body in, 105. 

Latta, 197. 

Lawrence, William, Mr., 153. 

„ William R., Dr., 60, 616. 
Lebert, M., 48. 
Leg, Amputation of, 391, 395. 

„ Re-amputation of, 392, 394. 

„ Wound of, 545, 548. 
Leucocythgemia, 479, 501. 
Lip, Cancer of, 49. 

„ Cancers of, Table of, 51. 

„ Upper Chancre of, 51. > 

Lisfranc, M., 21, 351, 386. 
Liston, Mr., 18, 107, 386. 
Lithotomy, 204, 218-226. 
Lithotrity, 204, 207-218. 
Local Anaesthesia, 621, 
Lothrop, Dr. J. R., 426, 428. 
Lungs, Wound of, 560, 564. 

M. 

Malformation of Foot, 612. 

Malgaigne, M., 322, 348, 349, 350, 352, 358. 

March, Prof, 72. 

Martin, Dr., 298. 

Melanosis of Eye, 56. 

„ of Parotid, 491. 

Mercier, M., 223. 
Meyer, 466. 

Minot, Dr. Francis, 145, 158, 303. 
Miscellaneous Cases, Chapter Xlll. 
Mons Veneris, Tumor of, 269. 
Morphia, Hypodermic Use in Neuralgia, 

467, 468, 471, 472. 
Morton, Dr. W. T. G., 497, 500, 614-616. 
Mussey, Prof., 405. 
Myeloid Tumors of Jaw, 64. 

N. 

Naevus over Knee-joint, 460. 

Neck, Encysted Thyroid Tumor of, 506. 



Neck, Hydrocele of, 509. 

„ Thyroid Tumor of, 507. 

„ Tumor of, 498, 502. 

„ the, Chapter IIL 

„ Wound of, 544, 558. 
Necrosis of Jaw, 88. 

„ of Skull, 576. . 
Needle penetrating Knee-joint, 590-592. 
Needles, Extraction of, 590. 
Nelaton, M., 73. 
Nerve, Excision of Digital, 475. 

„ Sciatic Wound implicating, 470. 
Nerves, Injuries and Diseases of, Chap- 
ter X. 
Neuralgia, Digital, 475-477. 
„ Facial, 472, 474. 
„ Traumatic, of Arm, 468, 471. 
Nitric Acid, Poisoning by, 578. 
Nitrous-oxide Gas, 622. 
Norris, Dr., 429. 
Nose, Deviation of Septum of, 62, 63. 

„ Epithelial Cancer of, 52. 

o. 

Occlusion of Vagina, 278, 280, 284, 286, 
287, 289. 

„ of Uterus, 291, 292. 

(Esophagus, Foreign Bodies in, 112, 113. 

„ Strictures of, 114-116. 

„ Tumors in, 116. 

Officers of Mass. General Hospital and 

McLean Asylum, 1846, 617. 
Oliver, Dr. H. K., Ill, 117, 119, 373, 377. 
Operation, Barton's, 417, 420. 

,, Pancoast's, 164. 

„ Pirogoff 's, 392. 

„ Syme's, 391. 

„ Wiitzer's, 167. 
Orbit, Tumor of, 57. 
Organs, Genito-urinary, Chapter VIL 
„ „ „ Female, 258. 

„ „ „ Male, 204. 

Otis, G. A., Surgeon U. S. V., 542. 
Ovariotomy, 300, 302. 



Page, Dr. C. G., 134. 

Paget, Mr., 47, 49, 270, 466, 524. 

Palate, Fissure of Soft and Hard, 126, 138, 
140. 

Pancoast, Prof., 164. 

Paracentesis Thoracis, 146. 

Parker, Dr. Willard, 138, 583. 

Parkman, Dr. George, 497. 

„ Dr. Samuel, 164, 497, 617. 

Parotid Region, Tumors of, 488, 

„ Tumor of, 489, 490-493, 495, 497. 
„ „ Scirrhous, 490. 

Parsons, Dr., 616. 

Patch, Dr., 105. 

Patella, Fracture of, 322, 332-338. 

Peirson, Dr. A. L., 143, 

Pelvis, Fracture of, 339. 
„ Wound of, 551, 561. 

Penetrating Wounds of Chest and Abdo- 
men, 569, 

Penholder removed from Bladder, 600. 

Penis, Indurated Tumor of, 245. 



INDEX. 



629 



Penis, Wound of, 552. 

Peruiajum, Rupture of, 258, 260, 261. 

Perineal Section, 230-232, 234-236, 238, 

240. 
Petrequin, Prof., 619. 
Pliimosis, 250. 
Pliysick, Dr., 175, 572. 
Pirogoff's Operation, 385, 392. 
Poisoning by Nitric Acid, 578. 
Pollock, Mr., 129, 131. 
Polypus of L'ecrum, 195, 196. 

„ of Utc-rus, 274-276. 
Priestly, Dr., 316. 
Prolapse of Anus, 194. 

„ of Bladder, 268, 269. 

„ of Walls of Vagina, 268. 
Prostate, Diseases of, 240. 
Putnam, Dr. Charles G., 519. 

R. 

Radius, Fracture of, 321, 330. 
RaA'er, M., 60. 

Re-amputation of Leg, 392, 394. 
Rectum and Anus, Imperforate, 196. 

„ Cancer of, 243. 

„ Polypus of, 195, 196. 
Recurrent Parotid Tumor, 497. 
Removal of Tonsils, 119, 121. 122. 

„ of Lower Jaw, 65, 66, 70, 78, 82. 
„ of Upper Jaw, 67, 81, 82, 84. 
Reid, Dr., 370. 

Renal Calculus in Female, 304. 
Restoration of Eyelid, Operations for, 42, 

44. 
Resuscitation after Drowning, 598. 
Retained Testicle, 257. 
Kevnolds, Dr. Edwii 
Rblgolene, 621, 622. 
Rhinoplastic Operations, 18. 
Rhinoplasty, Indian, 19, 33. 

„ ' Taliacotian, 30, 36. 
Richardson, Dr., 621. 
Richerand, M., 349. 
Robert, M., 376. 
Rodent Ulcer, 48, 53. 
Roux, M., 126, 129, 466. 
Rupture of Perin^eum, 258, 260, 261. 

„ of Tendon of Quadriceps Femo- 
ris, .338. 

„ Partial, of Tendon of Quadriceps 
Femoris, 582, 583. 

S. 

Salivary Calculus, 94. 

Sartorius Muscle, Tumor of, 529. 

Sawyer, Dr. A. A., 535. 

Scalp, Injuries of, 15. 

Schwerdt, 134. 

Scirrhous Tumor of Parotid, 490. 

Section, Perineal, 230-232, 234-236, 238, 

240. 
Septum Nasi, Deviation of, 62, 63. 
Shattuck, Dr. G. C, 125. 
Sliaw, Dr. B. S., 407, 527. 
Shoulder, Dislocations of, 348, 354, 356- 
358, 360, 361. 

„ joint. Amputation at, 387-389. 

„ „ Excision of, 411. 



Shurtleff, Dr., 616. 
Simpson, Dr., 301, 316, 597. 
Sims, Dr., 263. 
Skull, Fracture of, 2. 

„ „ of Base of, 3, 4, 597. 

Slade, Dr. D. D., 41, 149, 497. 
Smith, Dr., 331. 

„ Dr. J. V. C, 616. 
Smvly, Dr., 131. 
Souberbielle, Dr., 60. 
Spermatic Cord, Tumors of, 248. 
Stanley, Mr., 73, 376. 
Stearns, Dr. John, 584, 586, 589. 
Stone in Bladder (see Calculus), 204. 
Storer, Dr. H. R., 316. 

,, Prof. D. H., 600. 
Stricture of (Esophagus, 114, 

„ of Urethra, Perineal Section for, 
230. 

„ of Urethra, with Retention, 226. 
Subclavian Aneurism, 425, 427, 429. 
Swan, 466. 
Swinburne, Dr., 323. 
Syme, Mr., 206, 230, 385, 409, 466, 483. 

T. 

Table of Amputations, 409. 

„ of Cancers of Lip, 51. 

,, of Dislocations, 384. 

„ of Excisions of Joints, 423. 

„ of Operations for Cancer, 536. 

„ of Operations for Epilepsy, 15. 
Taliacotius, 18. 

„ Operation bv. Method of, 30, 

36. 
Tartra, 580. 
Taylor, Mr., 580. 

Tendon, Partial Rupture of Quadriceps, 
582, 583. 

" Rupture of Quadriceps, 338. 
Tendons, Painful Crepitation of, 580-582. 
Testicle, Retained, 257. 
Thigh, Amputation of, 386. 

„ Dislocation of, 353, 354. 

„ Fracture of, 323, 324. 

„ Gunshot "Wound of, 546, 565, 567. 
Thoracic Aorta, Aneurism of, 434. 
Thoracis Paracentesis, 146. 
Throat, Cancer of, 125. 
Tiedemann, 466. 
Tongue, Cancer of, 93. 

„ the, 92. 

„ Wound of, 552. 
Tonsils, Cancer of, 124. 

„ Removal of, 119. 
Townsend, Dr. S. D., 37, 366, 617. 
Trachea, Foreign Bodv in, 105. 
Tracheotomy, 108, 109\ 
Transposition of Organs, 125. 
Trephining for Epilepsy, 7-16. 

„ for Neuralgia, 472, 474. 

Tubercle, Painful Cutaneous. 535. 
Tumor, Adipose, of Hand, 521. 

„ „ of Cord, 248. 

,, containing Air, 576. 

„ Cystic, of Breast, 509. 

„ „ of Tibia, 522. 

„ „ of Vagina, 273. 

„ Encephaloid, of Thigh, 525. 



630 



INDEX. 



Tumor, Encephaloid, of Tibia, 524. 
Encysted, of Tongue, 92, 93. 

Tliyroid, 506. 
Erectile, of Breast, 510. 
„ of Cheek, 534. 
„ of Ear, 457. 
„ of Hand and Arm, 461. 
„ of Moutli, 462. 
„ of Mouth, Face, and 

Neck, 446. 
„ of Scalp, 443, 451. 
Fungoid, of Forehead, 483. 
Iliac, 179. 

Indurated, of Penis, 245-248. 
IMalignant, of Thigh, 527. 
of Arm, 519. 
of Axilla, 518. 
of Face and Neck, 504. 
of Face and Orbit, 499. 
of Head, 485, 487 
of Male Breast, 518. 
of Mons Veneris, 269. 
of Neck, 498, 502. 
of Orbit, 57. 

of Sartorius Muscle, 529. 
of Thigh, 530-533. 
Parotid, 489-493, 495, 497. 
Recurrent, of Cheek, 499. 

„ Fibrous, of Ear, 58. 
Thyroid, 507. 

Vascular and Sensitive, of Female 
Urethra, 270, 271. 
„ or Erectile, 441. 
Tumors, Chapter XI. 

Anenrismal, 424. 
ill CEsophagus, 116. 
of Jaw, 64. 
,, Cancerous, 80-84. 

„ Cystic, 72-80. 

„ Fibrous, 84. 

„ Myeloid, 64-70. 

of Lower Jaw secondary to Re- 
moval of Cancer of Lip, 86, 87. 
Parotid Region, 488. 



u. 



Ulcer, Rodent, 48, 53. 

Urethra, Bougie retained in, 229. 

„ Stricture of, Perineal Section for, 
230-232, 234-236, 
238-240. 
„ „ of, with Retention, 226, 

998 

Urethral Fistula from Wound, 235. 
Uterus and Vagina, Absence ot, 306, 308. 

„ Hypertrophy of Cervix of, 294, 
299. 

„ Occlusion of, 291, 292. 

„ Polypus of, 274-276. 

V. 

Vagina and Uterus, Absence of, 306-308. 
„ Foreign Body in, 276. 



Vagina, Occlusion of, 278, 280, 284, 286, 
287, 289. 

„ Prolapse of Walls of, 268. 

„ Tumor of, 273. 
Varicocele, 254-257. 

Varicose Aneurism of Hand and Arm, 461. 
Vascular or Erectile Tumor, 441. 
Velpeau, M., 212, 483, 581, 582. 
Venous Erectile Tumor of Mouth, 462. 
Vesical Calculus in Female, 303. 
Vesico-rectal Fistula, 234, 242. 

„ vaginal Fistula, 263-268. 
Virchow, Rudolf, Prof., 480. 
Vulva, Cancer of, 272. 



w. 



Walshe, Dr., 48, 124. 
Warren, Dr. J. Collins, 535. 

„ Dr. John, 143, 206, 489. 
„ Dr. John C, 81, 107, 122, 124, 
126, 162, 189, 206, 219, 346, 
353, 372, 376, 377, 450, 454, 
474, 479, 483, 485, 488, 497, 
518, 583, 605, 614-617. 
Wheeler, Dr., 6. 
White, Dr. J. C, 53. 
Whitton, John, 396. 
Wild, Dr., 587. 
Williams, Dr. H. W., 390. 
Wilson, Dr. E. T., 89. 
Wood, Mr. John, 164. 
Woodward, J. J., Ass't Surgeon U. S. A., 

542. 
Wound of Abdomen, 570. 

„ of Carotid Arterv, 439. 

„ of Chest, 570, 57*1. 

„ of Neck and Abdomen, 571. 

„ of Palmar Arch, 440. 

„ Gunshot, of Abdomen, 561. 

of Bladder, 241. 
„ „ of Chest, 550. 

„ „ of Elbow and Knee, 563. 

„ ,, of Groin, 565. 

„ of Head, 6, 543,555,556. 

„ „ of Leg, 545, 548. 

„ „ of Lungs, 560, 564. 

„ „ of Neck, 544, 558. 

,, „ of Os Calcis, 545. 

„ „ of Pelvis, 551, 561. 

„ ,, of Penis, 552. 

„ „ of Thigh, 546, 565, 567. 

,, „ of Tongue, 552. 

,, „ of Vertebral Artery, 553. 

„ „ followed by Neuralgia, 

468, 470, 471. 
Wounds, Gunshot, Chapter XIL 
Wrv Neck, 601, 605. 
Wlitzer's Operation for Hernia, 167. 
Wyman, Dr. Morrill, 147. 



Youatt, Mr., 587. 



ERRATA. 



Page 46, line 6, for " plain." 



read "plane. 



„ 55, , 


last, ., 


„ 60, , 


7, ,, 


„ 66, , 


18, „ 


„ 83, . 


19, » 


„ 86, , 


18, „ 


V 101, , 


13. „ 


„ 284, , 


27, „ 



" iris," 

" eucondromatous, 

"zigoma," 

" objections," 

•' similating," 

•' mucus," 

"pubis," 



cornea. ' 

eQchondromatous.' 
z3-goma." 
' objection." 
simulating." 
mucous." 
pubes." 



I 



I 



1 



